Coverage Criteria

Coverage Criteria A. Medicaid does not cover contact lenses when prescribed for routine correction of refractive errors. B. Medicaid covers contact lenses prescribed by an ophthalmologist or an optometrist when there is documentation that supports the following criteria: 1. Conventional eyeglasses will not result in acceptable visual correction, and 2. Contact lenses are medically necessary for the treatment of the following diseases or injury to the eye: a) Keratoconus, b) Keratoglobus, c) Irregular cornea astigmatism, d) Nystagmus, e) Progressive myopia over 6 diopters, where contact lens will improve visual acuity or retard the progressive myopia and lessen the frequency of prescription changes, f) Hyperopia over 3.5 diopters, where contact lenses will improve visual acuity, g) Anisometropia greater than 3 diopters or greater than 2.5, if there is documented intolerance to glasses as a result of anisometropia, h) Disease or deformity of the nose, skin, or ears that precludes the wearing of eyeglasses, i) Post-operative cataract surgery, or j) Treatment as a result of eye surgery, other than cataracts, which must be provided within six (6) months of the surgery to be covered. C. Corneal bandages when used as lenses are not covered as a separate reimbursement. The cost of the lenses is included in the payment for the physician and/or facility’s service. Providers should bill using the appropriate procedure code. Prior authorization is required. D. Prescriptions must include lens specifications such as power, size, curvature, flexibility, and gas-permeability for contact lenses. E. Medicaid does not cover for replacement of lost or stolen contact lenses. F. Prior authorization is required for all contact lenses. The request must properly document that one (1) of the diagnoses listed under coverage criteria is involved, and it must reflect that conventional eyeglasses is not an acceptable method of correction.