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RE: Medical Necessity for Custom Bilateral Scleral Contact Lens Fitting

Member: [Patient Name — verify] Member ID: ABC4471290 Group #: 77521 Payer: Anthem Blue Cross Blue Shield

To Whom It May Concern:

This letter is submitted to establish the medical necessity of custom bilateral scleral contact lens fitting for the above-referenced member, who carries a diagnosis of keratoconus, both eyes, with irregular astigmatism that cannot be adequately corrected with standard spectacle lenses, soft contact lenses, or corneal (standard) rigid gas-permeable (RGP) lenses.

Clinical Findings The patient presents with bilateral keratoconus associated with irregular corneal astigmatism secondary to corneal ectasia. Best-corrected visual acuity with spectacle correction is documented at 20/80 OD and 20/100 OS. A trial fitting with standard corneal RGP lenses was attempted and failed due to poor lens centration and lens intolerance (input-derived findings). Subsequent fitting with custom scleral lenses, which vault the irregular corneal surface and rest on the sclera rather than the cornea, improved best-corrected visual acuity to 20/25 in both eyes.

Medical Necessity Keratoconus produces corneal surface irregularity that cannot be corrected by standard refractive means because the optical irregularity occurs at the corneal surface itself rather than as a simple refractive error. In this case, spectacle correction leaves the patient with significantly reduced functional vision (20/80 OD, 20/100 OS), and standard RGP lenses were not tolerated due to poor centration on the irregular corneal surface, which is a recognized limitation of corneal-resting lens designs in irregular astigmatism/ectatic disease. Scleral lenses are indicated in this case not for routine refractive correction but as a medical intervention to (a) mask irregular corneal astigmatism that spectacles/soft lenses cannot correct, (b) vault the cornea to avoid the centration and comfort problems documented with standard RGP trial, and (c) restore functional visual acuity (documented improvement to 20/25 OU) necessary for activities of daily living, including safe driving. This is therefore a medically necessary service to treat a diagnosed corneal disease process, not an elective or cosmetic contact lens fitting.

Why Standard Options Are Inadequate

• Spectacle correction: does not correct irregular astigmatism from corneal ectasia; documented BCVA remains substantially reduced (20/80 OD, 20/100 OS).
• Standard soft contact lenses: conform to the irregular corneal surface and therefore do not adequately mask corneal-based irregular astigmatism (standard of care consideration; specific soft-lens trial data not provided in this record — verify if performed).
• Standard corneal RGP lenses: trialed and failed due to poor centration and lens intolerance, a well-recognized limitation of corneal RGP designs on irregular/ectatic corneas.
• Scleral lenses: uniquely address these limitations by vaulting over the irregular cornea and resting on the sclera, and are supported in this case by documented improvement in BCVA to 20/25 OU.

Anticipated Outcome With continued use of custom scleral lenses, the patient is expected to maintain functional visual acuity substantially improved over spectacle correction, supporting activities of daily living and driving safety, based on the visual acuity improvement already demonstrated during fitting/trial (20/25 OU).

Regarding Common Denial Concerns

• This request is not for a routine/cosmetic contact lens fitting; it is for treatment of a diagnosed corneal ectatic disease (keratoconus) where standard correction has failed.
• Medical necessity is supported by objective, documented failure of a lesser intervention (standard RGP lens trial) prior to progressing to scleral lens fitting.
• Objective visual acuity improvement (20/80 OD/20/100 OS to 20/25 OU) is documented with the scleral lens.

Additional clinical documentation that may be requested by the payer and is not addressed in the current record includes: corneal topography/tomography maps, pachymetry values, keratometry readings, formal classification of disease stability (stable vs. progressive/unstable) by the examining provider, duration and specific parameters of the failed RGP trial, and any relevant ocular or systemic history (e.g., allergies, prior ocular surgery) — these are not provided in the supplied record and should be verified/supplemented as needed to fully support the payer's review.

Applicable coverage policy criteria and payer-specific medical policy for scleral lens fitting in keratoconus should be reviewed by the payer and provider together, as specific LCD/NCD or Anthem medical policy language was not supplied for citation in this letter [verify].

We respectfully request coverage authorization for custom bilateral scleral contact lens fitting for this patient based on the documented diagnosis, failed conservative treatment, and objective functional visual improvement described above.

Sincerely, [Prescribing Optometrist/Ophthalmologist Name — verify] [License/NPI — verify] [Practice Name and Contact Information — verify]

Diagnosis Codes (ICD-10-CM) — from controlled H18.6 table only:

• H18.623 — Keratoconus, unstable, bilateral (verify code and payer rules). Note: the supplied record describes 'progressive corneal ectasia,' which suggests unstable disease, but the documentation does not explicitly use the formal stability designation ('stable' vs. 'unstable'). Confirm with the examining provider before final code selection; if stability is not confirmed, use of H18.603 (Keratoconus, unspecified, bilateral) may be more appropriate — verify with provider documentation. Do not substitute a unilateral or unspecified-eye code for this documented bilateral condition.

Procedure Codes (CPT) — all codes require verification against current CPT manual and payer-specific policy prior to submission:

• CPT 92071 — Fitting of contact lens for treatment of ocular surface disease, unilateral (verify code and payer rules; confirm bilateral reporting convention, e.g., -50 modifier or 92072 usage per payer rules).
• CPT 92072 — Fitting of contact lens for management of keratoconus, bilateral (verify code and payer rules — confirm this is the payer's preferred bilateral code over 92071 with modifier).
• HCPCS supply codes for scleral lens material (e.g., V2530–V2531 or V2627–V2628 series) — specific code depends on lens design and payer supply-billing policy (verify code and payer rules).

Note: All codes listed above are suggested for provider/coder review only. Do not submit without independent verification of current CPT/HCPCS/ICD-10-CM code sets, payer medical policy, and correct laterality/stability documentation.