Note: Many Aetna medical plans exclude coverage of contact lenses or eyeglasses. Under medical plans with this exclusion, contact lenses are only covered under medical plans for a narrow set of therapeutic indications, as outlined below. Additional coverage of contact lenses and eyeglasses may be provided under the member's vision care plan, if any. Please check benefit plan descriptions for details.

1. Prosthetic Contact Lenses and Eyeglasses for Aphakia

   1. Medicare plans and HMO plans (HMO, QPOS)

      For Aetna Medicare plans and Aetna HMO plans, Aetna follows Medicare's rules for prosthetic lenses.

      For Aetna Medicare members and HMO members, Aetna considers external lenses (contacts or spectacles) and intraocular lenses medically necessary after cataract surgery. CMS defines both types of lenses as “prostheses” replacing the lens of the eye. This includes post-surgical external lenses that are customarily used during convalescence from cataract removal surgery. In addition, an intraocular lens is considered a medically necessary prosthetic for individuals lacking an organic lens because of surgical removal (e.g., cataract surgery) or congenital absence (congenital aphakia). Note: Aetna covers medically necessary external and internal lenses as prosthetics for aphakic members even if the surgical removal of the member's lens occurred before the member enrolled in Aetna's medical plan.

      For Medicare and HMO members, Aetna's considers the following lenses or combinations of lenses medically necessary following cataract surgery to essentially restore the vision provided by the crystalline lens of the eye. These may include:

      • Bifocal spectacles; or
      • Spectacles for far vision or for near vision; or

      • When a contact lens(es) for far vision is prescribed (including cases of binocular and monocular aphakia), Aetna considers medically necessary both the contact lens(es) and for spectacles for near vision that are worn either simultaneously with the contact lenses or when the contact lenses have been removed.

      For Medicare members and HMO members, Aetna medical plans consider medically necessary lenses with ultraviolet (UV) protection in lieu of regular (untinted) lenses for aphakia. UV coating is considered medically necessary when applied to a glass lens material.

      Antireflective coating, tints, or oversize lenses are not generally considered medically necessary; the medical necessity of such features must be documented by the treating physician.

      Aetna considers not medically necessary cataract sunglasses (i.e., tinted lenses, including photochromatic lenses (lenses in which the tint changes in response to light)) that are prescribed in addition to regular (untinted) lenses for aphakia because the sunglasses duplicate the restoration of vision function performed by the regular lenses.

      Aetna considers the following features not medically necessary:

      • Scratch resistant coating;
      • Mirror coating (colored, highly-reflective lens treatments);
      • Polarization;
      • Progressive lenses (i.e., multifocal lens that gradually changes in lens power from the top to the bottom of the lens, eliminating the lines that would otherwise be seen in a bifocal or trifocal lens);
      • Eyeglass cases.

      Lenses made of polycarbonate or other impact-resistant materials (e.g., Trivex) are considered medically necessary for members with functional vision in only one eye. Use of polycarbonate or similar material or high index glass or plastic for indications such as light weight or thinness is considered not medically necessary.

      Standard eyeglass frames are considered medically necessary for persons who meet criteria for refractive lenses. Deluxe frames are considered convenience items.

      Under Medicare and HMO plans, Aetna considers eyewear a medically necessary prosthetic for aphakic members who have not had an intraocular lens replacement. Since these members lack an internal lens, their contact lenses or eyeglasses are considered to be prosthetics. For Medicare and HMO plans, Aetna medical plans consider medically necessary the first pair of glasses or aphakia contact lenses after cataract surgery and an additional pair of lens(es) each time the member's prescription changes. Requests for replacement of lost or broken glasses or lenses will be reviewed on an individual basis. (There is a CMS requirement for consideration of replacement of lost or broken contact lenses or eyeglasses for Medicare members who have had cataract surgery.)

      Note: For Medicare and HMO members who have had cataract surgery with insertion of an intraocular lens (IOL), Aetna Medicare and HMO plans, by administration, will cover no more than one pair of eyeglasses or contact lenses after each cataract surgery. Replacements of conventional eyeglasses or contact lenses are not covered under these medical plans. The member may have additional eyewear coverage through a vision care rider.

   2. Traditional (non-HMO) plans (Indemnity, PPO and MC POS plans)

      While contact lenses and eyeglasses are rarely used in place of intraocular lenses in aphakia, contact lenses and eyeglasses are considered medically necessary under traditional medical plans as a prosthetic device following cataract surgery in lieu of intraocular lenses. Note: Most Aetna plans exclude coverage of contact lenses and spectacles. Under these plans, eyeglasses and contact lenses in non-aphakic members, including those who have had intraocular lenses implanted after cataract surgery, are not covered under medical plans. Contact lenses and eyeglasses may be covered under the member's vision care plan.

   3. Note on coverage of contact lenses for aphakia in infants and children

      Note: Most Aetna plans exclude coverage of contact lenses. Please check benefit descriptions for details. As an exception to Aetna's standard policy, Aetna covers by administration contact lenses under its medical plans for infants who undergo cataract surgery. If cataract removal surgery is performed on one eye, Aetna will cover one contact lens initially following surgery, and will cover an additional replacement lens each year until the child's fifth birthday.* If cataract removal surgery is performed on both eyes, Aetna will cover two lenses initially, and two replacement lenses annually until the child reaches his or her fifth birthday. Replacement contact lenses are not covered under the medical plan beyond the child's fifth birthday. From that point, replacement contact lenses may be covered according to the terms of the member's vision care plan.

      Aetna recognizes that the child may require multiple contact lens replacements through the course of a given year. Aetna's agreement, however, is to pay for one replacement lens (or one set of lenses) on an annual basis under its medical plans. Payment for additional lenses may be covered under the member's vision care plan.

2. Therapeutic Hydrophilic Contact Lenses (Corneal Bandage)

   Therapeutic soft (hydrophilic) contact lenses or gas-permeable fluid ventilated scleral lenses (e.g., Boston Scleral Lens) are considered medically necessary prosthetics under medical plans where used as moist corneal bandages for the treatment of severe ocular surface diseases, including

   1. Corneal stem cell deficiency (Stevens-Johnson syndrome/TEN, chemical and thermal injuries to the eye including surgical procedures, aniridia, idiopathic corneal stem cell deficiency and ocular pemphigoid); or

   2. Neurotrophic (anesthetic) corneas, such as may result from:

      1. Congenital etiologies, such as congenital corneal anesthesia (familial dysautonomia), Seckle's syndrome; or

      2. Acquired etiologies, such as may result from acoustic neuroma surgery, trigeminal ganglionectomy, trigeminal rhyzotomy, herpes simplex/zoster of the cornea, diabetes; or

   3. Severe dry eyes (keratoconjunctivitis sicca) (such as from Sjogren's syndrome, chronic graft versus host disease, radiation, surgery, meibomian gland deficiency); or
   4. Corneal disorders associated with systemic autoimmune diseases (rheumatoid arthritis, dermatological disorders such as atopic, epidermolysis bullosa, epidermal dysplasia); or
   5. Epidermal ocular disorders (atopy, ectodermal dysplasia, epidermolysis bullosa); or
   6. Corneal exposure (e.g., anatomic, paralytic). 

      Corneal bandages are considered experimental and investigational for all other indications.

      Note: Liquid bandage scleral lenses are covered under plans that exclude coverage of contact lenses, as these lenses are not primarily for correction of refractive errors.

      Note: For scleral lenses for masking irregular astigmatism, see section below. 

   Replacement lenses are considered medically necessary under medical plans if required because of a change in the patient's physical condition (not including refractive changes). Note: Charges to replace contact lenses that are lost, damaged, or required solely due to refractive changes are not covered under medical plans.

3. Scleral Shell Contact Lenses

   Scleral shell contact lenses are considered medically necessary under medical plans for the following indications:

   1. When prescribed to support orbital tissue (such as where an eye has been rendered sightless and shrunken by inflammatory disease); or

   2. For the treatment of keratoconjunctivitis sicca or “dry eye.”

   Replacement lenses are considered medically necessary under medical plans if required because of a change in the member's physical condition (not including refractive changes). Note: Charges to replace contact lenses that are lost, damaged, or required solely due to refractive changes are not covered under medical plans.

   Note: Scleral shell lenses are covered under plans that exclude coverage of contact lenses, as scleral shell lenses are not primarily for correction of refractive errors.

4. Contact Lenses and Eyeglasses for Accidental Injury

   An initial pair of contact lenses or eyeglasses is considered medically necessary under medical plans when they are prescribed by a physician to correct a change in vision directly resulting from an accidental bodily injury. Note: Charges to replace such contact lenses or eyeglasses are not covered under medical plans.

5. Contact Lenses for Masking Irregular Astigmatism Associated with Keratoconus and Other Corneal Disorders

   Aetna medical plans consider medically necessary services required by members undergoing an evaluation of keratoconus or other corneal disorders associated with irregular astigmatism (e.g., keratoglobus, pellucid corneal degeneration, Terriens marginal degeneration, post-LASIK ectasia, corneal scarring).  This includes the general examination, advanced corneal topographic modeling, and fitting of contact lenses or scleral lenses.

   Note: Most Aetna medical benefit plans exclude coverage of contact lenses and other vision aids. Please check benefit plan descriptions for details. These benefit plans do not cover contact lenses or scleral lenses for correcting astigmatism associated with keratoconus or other corneal disorders under medical plans that exclude coverage of contact lenses and eyeglasses. This includes corneal contact lenses and scleral lenses that may be prescribed for masking irregular astigmatism associated with corneal ectasia (e.g., keratoconus, keratoglobus, pellucid corneal degeneration, Terriens marginal degeneration, post-LASIK ectasia), postoperative astigmatism (e.g., following refractive surgery or corneal transplant), corneal scarring (e.g., from trauma, infection, or Hydrops), and anterior corneal dystrophies (e.g. Meesman's, Cogan's).  Contact lenses and scleral lenses provided to members with keratoconus and other corneal disorders associated with irregular astigmatism are covered under the provisions of the member's vision care plan only.

*Note: Some HMO plans cover only an initial prosthetic, and exclude coverage of replacements of prosthetics regardless of medical necessity. Under these plans, only an initial set of glasses or contact lenses are covered under the medical plan. Please check benefit plan descriptions for details.

Therapeutic soft hydrophilic contact lenses are made of poly-2-hydroxyethyl methacrylate and other flexible plastics. They are about 13 to 15 mm in diameter and cover the entire cornea. Hydrophilic contact lenses may be prescribed for the treatment of bullous keratopathy and other corneal disorders (bandage lenses). Prophylactic antibiotic eye-drops may be used with a bandage lens. Most therapeutic eye-drops can be used with hydrophilic lenses.

The Boston Scleral Lens is a fluid-ventilated scleral lens designed to enclose aqueous fluid over the corneal surface. The scleral lens acts as a corneal bandage, and can mask irregular astigmatism.  The scleral lens rests entirely on the sclera and avoids all contact with the cornea.  Thus, the scleral lens can be used by persons who are intolerant to standard (hard) contact lenses, which rest on the sensitive cornea. The Boston Scleral lens has a series of channels that aspirate tears into the fluid reservoir while preventing the formation of air bubbles in the reservoir.

Scleral shell (or shield) is a catchall term for different types of hard scleral contact lenses. A scleral shell fits over the entire exposed surface of the eye as opposed to a corneal contact lens that covers only the central nonwhite area encompassing the pupil and iris.

When an eye has been rendered sightless and shrunken by inflammatory disease, a scleral shell may, among other things, obviate the need for surgical enucleation and prosthetic implant and act to support the surrounding tissue. In such a case, the device serves essentially as an artificial eye.

Scleral shells are occasionally used in connection with artificial tears in the treatment of “dry eye” of diverse etiology. Tears ordinarily dry at a rapid rate, and are continually replaced by the lacrimal gland. When the lacrimal gland fails, the half-life of artificial tears may be greatly prolonged by the use of the scleral shell contact lens as a protective barrier against the drying action of the atmosphere. Thus, the difficult and sometimes hazardous process of frequent instillation of artificial tears may be avoided. The lens acts in this instance to substitute, in part, for the functioning of the diseased lacrimal glands and would be considered a prosthetic device in the rare case when it is used in the treatment of dry eye.