Keratoconus: Costs and Considerations

Keratoconus patients are desperate to find a solution to their visual problems that most people take for granted. People don’t think of vision as being problematic. Keratoconus patients must contend with contact lenses or contemplate a surgical procedure to improve the quality of their life. Eyeglasses usually do not provide adequate sight to perform most daily tasks. So the keratoconus patient must rely on a visual device on the already fragile cornea, due to the thinning of the cornea to gain optimal acuity. It is an understatement to state that the lifestyle is altered due to this corneal abnormality. Navigation at night is difficult and the questionable constant conscious state of comfort and vision plagues the keratoconus mindset.

Cost for therapeutic devices for the keratoconus patient can limit the solutions. Major medical insurance companies should cover this medical anomaly. The attitude of the insurance companies is to force the patient to go through barriers before payment is guaranteed. It is my experience that most keratoconus patients are so hopeful of the expected outcome that they pay for the care and take on the insurance companies by themselves. This usually results in the keratoconus patient giving up on the insurance companies because of the time it takes to convince the insurance company that the procedure is not a cosmetic procedure but a medical necessity. The goal of this article is to provide the keratoconus patient with the ammunition to gain payment for this medical procedure..Keratoconus gradually causes the central area of the cornea to weaken, thin or bulge. It eventually distorts from its more spherical shape to a cone shape. This distortion may cause significant changes in vision which may begin in the late teen years and may not stop until age 40. While keratoconus can be an inherited bilateral (two eye) condition, many patients have no clear inheritance pattern. It has been estimated to occur in 1 out of every 2,000 persons.The earliest changes of keratoconus may require frequent changes of glasses. As the corneal distortion worsens, contact lenses may be required to obtain adequate vision. In this case, contact lenses mask the warp or cone-like changes of the underlying cornea. Generally, most keratoconus patients can be safely managed with contact lenses yielding good vision and comfort..In more advanced cases of keratoconus, vision in an eye can be suddenly, yet usually temporarily, lost through an event called “hydrops.” During this process, the stretching cone-area of the cornea cracks, swells and in some cases scars..When contact lenses can no longer correct vision adequately, or when highly specialized contact lenses can no longer be made to remain comfortably on the eye surface, surgical replacement of the distorted corneal area may be considered with no guarantee of success. Surgical treatment is found to be necessary in only about 10% of the cases. This surgery is performed using donor cornea tissue to return the eye surface to a more normal shape. Patients who handle their keratoconus problems successfully develop their own coping mechanisms. Sunglasses are advised to reduce glare symptoms. The condition may be easily diagnosed by using instruments such as the corneal topographer which measures the central corneal curvature. As the condition progresses the curvature readings become steeper and begin to appear irregular. Computerization of this corneal mapping process adds sophisticated algorithms to the intricate process of understanding the complex surface of the front of the eye. Corneal topography is a modern invaluable tool to assist in the diagnosis and treatment of keratoconus.

Contact Lenses or Eye Surgery?

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.

The ultimate cost of Keratoconus can vary per patient. Give us a call to discuss further at (708) 634 – 4146 or fill out an appointment request form so we can be in touch.

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..For more information please consult Dr. Brad Cogswell at our Oak Lawn office..