Added to the frustration of the blurry world that keratoconus patients live in is the fact that many health plans have barriers to getting optimal eyecare. The most useful treatment for many is GP or specialty contact lenses that correct distorted vision. These lenses, and the associated costs of fitting them, can run hundreds or even thousands of dollars. Yet many insurance plans do not cover contact lenses based on the premise that they are ‘cosmetic’.
And now, an effective treatment for the progressive keratoconus – crosslinking – has been approved by the FDA, yet it is rarely covered by health plans.
Anyone who has battled insurance companies knows about Medical Policy documents. Each health plan has a list of services that are covered and noncovered. These policies are written by the insurer and explain their conclusions about the standard of care for policy holders. To be an educated consumer, you should take some time and investigate exactly what your plan will cover. (Sometimes vision services are in a separate document, or fall under a vision plan instead of medical benefits.) Almost all of this information can be found on the insurer’s website.
In the Medical Policy or Covered Services section of your plan’s website, type in the keyword ‘keratoconus’ or ‘scleral lenses’ or ‘contact lenses’. Here are some actual examples from May 2017:
From Aetna: Aetna considers services that are part of an evaluation of keratoconus or other corneal disorders associated with irregular astigmatism medically necessary. This includes the general examination, advanced corneal topographic modeling, and fitting of contact lenses or scleral lenses.
(But are the costs of the lenses also covered?)
From Excellus Blue Cross: Based on our criteria and assessment of peer-reviewed literature, a gas permeable scleral lens is considered medically appropriate for patients who have not responded to topical medications or standard spectacle or contact lens fitting for keratoconus.
(The doctor will need to document that the patient has tried and failed standard eyeglasses and contacts before fitting scleral lenses.)
From Blue Cross of Kansas: Standard soft contacts are not allowed for the management of keratoconus. They are considered non-covered since the soft contact lens used for this diagnosis is to improve vision, not to alter the progression of the disease. Contact lenses that are prescribed to diminish the progression of the disease and NOT to correct a vision problem will be allowed based on benefits.
(It appears that doctors can only prescribe soft lenses to treat disease progression, which is not the standard of care!)
From Well Sense Health Plan: Scleral lens is covered for a member when ALL of the following criteria are met and documented in the member’s medical record. A request for scleral lens requires Plan Medical Director review and approval.
(Sounds hopeful. This plan will approve scleral lenses for KC patients, but they require documentation and additional review and approval by the Plan’s Medical Director in order to process payment.)
Patients interested in Crosslinking have learned that this procedure is covered by very few insurance plans. In the year since the FDA approval, about a dozen plans have changed their Medical Policy to include CXL; the number of plans that will cover the costs of crosslinking is small, but growing each month. Again, the more you know before you schedule the procedure, the fewer surprises. Here are a few excerpts from current (May 2017) Medical Policies:
From Aetna: Aetna considers epithelium-off photochemical collagen cross-linkage using riboflavin and ultraviolet A medically necessary for keratoconus. . . Aetna considers epithelium-on (transepithelial) collagen cross-linkage experimental and investigational for keratoconus. . . Aetna considers performance of photochemical collagen cross-linkage in combination with other procedures (CXL-plus) (e.g., intrastromal corneal ring segments, PRK or phakic intra-ocular lens implantation) experimental and investigational.
(It appears they will cover epi-off CXL, but not epi-on CXL or a combined procedure.)
From Blue Cross of North Carolina: Corneal collagen cross-linking is considered investigational for all applications. BCBSNC does not provide coverage for investigational services or procedures.
From Anthem Blue Cross: Corneal collagen crosslinking (CXL) is considered investigational and not medically necessary for all indications.
From United Healthcare: Collagen cross-linking of cornea analysis is unproven and not medically necessary due to insufficient clinical evidence of safety and/or efficacy in published peer-reviewed medical literature.
(These plans and others need to be educated that CXL is now standard of care for progressive KC and is supported by peer-reviewed literature.)
If your insurer still considers CXL experimental, you’ll be fighting a bigger battle than just seeking reimbursement for a covered service. You’ll need to explain why this is the appropriate treatment for you.
What to do?
- Know what your insurance policy states in their Medical Policy about the procedure or treatment you are seeking.
- Confirm your understanding with your doctor’s office. Many doctors will submit a preapproval request to the insurance carrier to find out if it will be covered. (Note that even if a service or treatment is ‘approved’, it doesn’t mean it will be reimbursed at a level that approaches the charges for the treatment.)
- If you have to pay out of pocket to the doctor for the service, and you are seeking reimbursement from the insurance company, ask your doctor to provide you with a letter explaining the medical necessity for the treatment and a summary of your test results and past treatments. For example, your doctor will need to state that you have a diagnosis of progressive keratoconus and provide medical documentation.
Educate yourself . . .
To learn more about working with insurance companies, the Patient Advocacy Foundation has a very useful publication called, “A Patient’s Guide to Navigating the Insurance Appeals Process.” To download a copy, visit their website at www.patientadvocate.org.