Does Medicare Cover Scleral Lenses?

Medicare provides limited coverage for routine vision care, including standard eye exams, eyeglasses, or conventional contact lenses. Exceptions exist for vision-related services and items when considered medically necessary to treat a disease, injury, or specific medical condition. Scleral lenses, while often used for vision correction, may fall under this medical necessity exception in certain circumstances.

General Medicare Vision Policy

Original Medicare, which includes Part A (Hospital Insurance) and Part B (Medical Insurance), does not cover routine eye care services. This means regular vision check-ups, refractions to determine a prescription for glasses, and the cost of eyeglasses or contact lenses for general vision correction are not covered benefits. This approach reflects Medicare’s design to cover medically necessary services rather than elective or routine care.

However, Medicare Part B does cover certain vision-related services when tied to the diagnosis and treatment of specific medical conditions. For example, eye exams for detecting and treating glaucoma or cataracts are covered. Surgical procedures for conditions like cataracts, and corrective lenses immediately following cataract surgery, also receive coverage.

Scleral Lens Coverage Criteria

Scleral lenses are considered for Medicare coverage only when medically necessary and functioning as a prosthetic device to treat severe eye conditions. They are not covered when prescribed simply for general vision improvement. The medical necessity for scleral lenses arises when less specialized contact lenses or eyeglasses cannot adequately correct vision or manage a specific ocular disease.

Severe eye conditions warranting medical necessity for scleral lenses include:
Keratoconus, a progressive eye disease where the cornea thins and bulges into a cone shape.
Corneal ectasia, which involves similar corneal irregularities.
Severe dry eye syndrome that has not responded to conventional treatments.
Complications following corneal transplants.
Severe ocular surface diseases.
Irregular astigmatism resulting from injury or surgery, where the unique design of scleral lenses can provide a stable and therapeutic optical surface.

A comprehensive diagnosis and detailed prescription from an eye care professional are essential to establish this medical necessity.

Medicare Plan Types and Scleral Lenses

If scleral lenses are determined to be medically necessary, coverage falls under Medicare Part B for those with Original Medicare. Part B covers medically necessary durable medical equipment (DME) and prosthetic devices, including certain types of corrective lenses when they serve a prosthetic purpose. After meeting the annual Part B deductible, Original Medicare covers 80% of the Medicare-approved amount for these services.

Medicare Advantage Plans (Part C) are offered by private companies approved by Medicare. These plans must cover everything Original Medicare Part A and Part B cover, and often provide additional benefits, including broader vision coverage. Some Medicare Advantage plans offer more comprehensive benefits for medically necessary scleral lenses, potentially with different cost-sharing structures like fixed copayments. Beneficiaries should review their specific plan’s Evidence of Coverage (EOC) document to understand the full scope of vision benefits and any specific requirements for specialized lenses.

Medicare Part D plans primarily cover prescription drugs and are not relevant to scleral lens coverage. Medigap policies (Medicare Supplement Insurance) are private plans that help pay for out-of-pocket costs not covered by Original Medicare. These policies can assist with expenses like deductibles, coinsurance, and copayments associated with medically necessary services covered under Medicare Part B, which would include qualified scleral lens costs.

Securing Scleral Lens Coverage

Obtaining Medicare coverage for scleral lenses begins with a comprehensive eye examination by a qualified ophthalmologist or optometrist. This eye care professional must document the specific medical condition necessitating the lenses and clearly articulate why standard corrective options are ineffective. A detailed prescription explicitly stating the medical need for scleral lenses as a prosthetic device is a foundational requirement.

Many Medicare plans, especially Medicare Advantage plans, require prior authorization before specialized medical equipment like scleral lenses are dispensed. This process involves the eye care provider submitting documentation to the Medicare plan for approval before the lenses are ordered or fitted. The documentation must thoroughly support the medical necessity for the lenses, demonstrating they are an integral part of treating a severe eye condition.

Ensure scleral lenses are obtained from a Medicare-enrolled supplier who accepts assignment. Accepting assignment means the supplier agrees to accept the Medicare-approved amount as full payment for the service or item, which can help limit out-of-pocket costs. If a claim for medically necessary scleral lenses is initially denied, beneficiaries have the right to appeal the decision. The appeals process requires strong supporting medical records and continued advocacy from the prescribing physician.

Patient Cost Share

Even when Medicare covers medically necessary scleral lenses, patients incur out-of-pocket costs. For those with Original Medicare, the Part B deductible must be met before Medicare begins to pay its share. In 2025, this annual deductible is an estimated $250.

After the Part B deductible is satisfied, Original Medicare covers 80% of the Medicare-approved amount for medically necessary scleral lenses. This leaves the patient responsible for the remaining 20% coinsurance. For individuals enrolled in Medicare Advantage plans, the cost-sharing structure may differ, often involving fixed copayments rather than percentage-based coinsurance. These copayment amounts can vary significantly between different Medicare Advantage plans.

Costs for routine eye exams, non-medically necessary fittings, or cosmetic aspects of lenses are not covered by Medicare. Medigap policies can reduce a patient’s financial burden by covering some or all deductibles, coinsurance, and copayments that Original Medicare beneficiaries would otherwise be responsible for. However, Medigap plans do not cover services that Original Medicare itself does not cover.