Cosmetic versus Medical Procedure

Approximately 85% of all contact lenses are worn for either convenience or appearance and 15% are worn for the visual advantages possible with certain conditions such as severe nearsightedness, severe astigmatism, and following cataract removal. Although the contact lenses are of great benefit for those with severe visual conditions, eyeglasses can still be worn as an alternative, although vision might not be as good. With keratoconus, however, eyeglasses cannot provide adequate vision because of the conically deformed cornea. The only non-surgical method to provide adequate vision for the keratoconus patient is replacing the deformed cornea with a regular front surface for the eye -this is accomplished by the fitting of a special rigid contact lens. If contact lenses cannot be worn, then the only alternative is corneal transplant surgery. This is the key in getting the insurance companies to pay attention to the nature of the therapeutic remediation. The choice you are giving the insurance company is either the less expensive contact lens or the more expensive corneal transplant. Both are medical procedures for the anomaly of keratoconus.

Insurance coding is another important procedure that must be included in the submission for insurance coverage. There are two parts included for insurance submission. The first is the diagnostic code and the second is the examination and treatment. The (International Classification of Disease 9th Revision Clinical Modification) ICD-9-CM code is 371.61, 371.70 defined as bilateral bulging protrusion of anterior cornea, often due to non-inflammatory thinning. The (Current Procedure Terminology) CPT code is 92070 defined as fitting of contact lens for treatment of disease, including supply of lenses. Another approach is to submit for the evaluation including corneal topography (92499), the contact lens fitting and instruction (92310) and the lens material separately (V2511). Symptoms associated with keratoconus can be described to enhance the submission such as blurred vision (368.8), irregular astigmatism (367.22), monocular diplopia (368.2), Photopobia (368.13), Cornea striae (371.32), Corneal scarring (371.00) and/or Corneal Fleischers Ring (371.11). Most insurance carriers verify that the visual acuity through contact lenses will be an improvement over glasses for full coverage under the medical umbrella.

Patients who have major medical coverage pay monthly premiums in the event that they are afflicted with a health anomaly to minimize their financial responsibility. Premiums increase yearly as the insurance companies’ gamble that their incidence will offset their liabilities. Insurance statistics provide the risk analysis that quantifies the monetary exposure for the diagnosis and treatment of keratoconus. It is necessary that we educate the underwriters that keratoconus is no less severe than any other medical disorder. A contact lens is essential to provide a smooth optical surface on the cornea for optimal vision. The topographical map is an objective test defining the corneal disorder. The contact lens is not cosmetic but is a prosthetic device, which allows the patient to continue to perform daily activities.