Insurance is paying for my scleral lens!

[Jill Marie]

Hi to everyone that has gotten the scleral lens and those that would like to but are concerned about the cost.  I copied and pasted the following from a post Dena King made on another thread about how she got her lens paid for.  Dena is the one that brought this wonderful lens to our attention, Thanks again Dena!

1.  Scleral lens.  Mine was about $1200 which included exam I believe which was denied by insurance 2 times.  Then I got very angry and filed an appeal with the commonwealth of Kentucky public protection cabinet, department of insurance, health and life division per advice from my dr.

My ophthalmologist, and lens docs both wrote letters explaining my past, and I also, wrote a letter.
I am pleased to say the state ruled in my favor stating the vision exclusion for contact lens does not apply to my case pursuant to Exposure Keratitis 370.34, Dry Eye Syndrome 375.15, secondary to Facial Paralysis 351.9, due to an acoustic neuroma 225.1,

The Kentucky dept of insurance said pursuant to KRS 304.17A-617(3)(d), HHP must cover scleral
Lens.  My insurance responded to me within a week, however I had not met my $5000 deductible fully and most of it was applied to that.

I am sure all states have public insurance departments that you all can try.  I sure hope this helps! Dena

My insurance co. rejected the first claim and the first appeal, seems that's customary, they reject the claims on the basis of your coverage.  I gave my eye doctor a copy of Dena's post so she would know how Dena's lens got paid for.  I have no idea what my doctor wrote.  I also wrote a letter stating that I was close to applying for disability do to the pain from my eye and the trouble I was having working because of it.  I also said that the lens didn't have a prescription in it, it was only being used to preserve my eye.  I've been really busy so I'm not sure about the time frame but I think it only took a couple of weeks for the insurance company to decide in my favor. 

The letter I got says:  After reviewing all of the information submitted with your appeal, the Appeal Panel determined that the contact lens was medically necessary to treat a medical condition and not a vision care item excluded by your healthcare plan. 

I would have gotten the lens even if the Insurance company wouldn't pay for it, it's that good, having it paid for is an extra bonus and helps pave the way for future claims if I need them. 

Take Care,  8)Jill Marie

[saralynn143]

That is wonderful, Jill Marie! I am delighted for you.

My doctor's office is still working with the insurance company. I will take this information with me next visit just in case.

I have been thinking about it - the Boston Foundation for Sight PROSE lenses are almost always approved because it is called a prosthetic device rather than a contact lens. It is much more expensive than other scleral lenses as well.

Anyway, a scleral lens for those of us without eyelid function is by necessity a prosthetic device. A cost-analysis would show that a lens is cheaper in the long run than treating corneal disease or accident caused by poor vision.

I would not request the insurance company pay for a contact for my right eye, but the scleral for the left just seems reasonable.

[Jill Marie]

Hi Sara, 

I agree, you shouldn't have any trouble getting the Insurance co. to pay for the lens, sometimes it just takes a bit to get the right info. to the Insurance co. so they cover it.  It's nice to know that we all have options depending on our income and Insurance coverage.  Since my lens only cost $250 someone with no Insurance or a high deductible could give it a try, has to be better than what they are going through. 

Keep me posted on your Insurance claim and the lens of course!  Jill Marie

[nancyann]

Jill Marie and Dena: thanks so much for the insurance info. I just emailed my ophthalmologist!

[Jill Marie]

Hi Nancyann,

Don't stop tell they pay for the lens!  Was just thinking that perhaps I will read a good book, haven't done that in years, hated having to stop reading all the time to put ointment in my eye, don't have to do that now so a book is looking really good, nothing like relaxing in the back yard on a nice summer day reading a book that makes you forget everything else. 

Let us know what the Insurance co. says, Jill Marie

[Dena King]

It has been so long since I have been on here and am so touched that my information about the scleral lens has helped you all.  I continue to wear mine.  I am having a lot of hearing issues.  Losing my hearing in right ear and the docs can't figure it out.  The last doc basically said it was genetics and just from getting older.  MRI is not showing anything, but I am really scared I am going to be totally deaf.  Trying to figure out where I should go.  Have considered the house ear clinic.
Dena

[Jill Marie]

Hi Dena,

Yes, we are truly thankful that you helped us get relief from our dry eye problems.  I for one will never forget your name as you are the one that helped me keep my job, saved my bank account and helped me "see" a brighter future!  So sorry to find out that after finally getting your eye issues taken care of you are now dealing with hearing issues.  I'm hoping that the doctors have figured out what is going on and that they can help you. 

Please let us know how you are doing!  Jill