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Billing Medically Necessary Contacts

Comprehensive guide for VSP, EyeMed, Spectera, and Superior vision plans

What Qualifies as Medically Necessary?

Contact lenses are considered medically necessary when they provide significantly better vision than spectacles or are required for specific medical conditions.

Qualifying Conditions

  • • Keratoconus - H18.601-H18.629
  • • High refractive error - Anisometropia ≥3D (H52.31, H52.32)
  • • Irregular astigmatism - H52.211-H52.223
  • • Aphakia - Post-cataract, no IOL (H27.01-H27.03)
  • • Post-surgical conditions - Corneal transplant, refractive surgery complications
  • • Corneal scarring - H17.0-H17.9
  • • Pellucid marginal degeneration - H18.73

CPT Codes for Medically Necessary Contacts

92310 - Prescription of Optical and Physical Characteristics, Contact Lens Fitting (Corneal)

Use for standard corneal contact lens fitting

RVU: ~1.5

92311 - Corneal Contact Lens for Aphakia, One Eye

Specific code for aphakic patients

RVU: ~2.0

92312 - Corneal Contact Lens for Aphakia, Both Eyes

Bilateral aphakic fitting

RVU: ~3.0

92313 - Corneoscleral Contact Lens

For larger diameter lenses (scleral, semi-scleral)

RVU: ~2.5

92314 - Prescription of Optical and Physical Characteristics, Contact Lens Fitting (Gas Permeable, Complex)

For keratoconus, irregular astigmatism, or other complex fits

RVU: ~3.0

92071 - Fitting of Contact Lens for Treatment of Ocular Surface Disease

Bandage contact lenses, PROSE lenses

Often requires TC modifier

VSP (Vision Service Plan)

Billing Requirements

  • • Bill either through the Eyefinity portal OR by CMS-1500 paper claim form depending on the provider workflow
  • • If using Eyefinity:
    • - Create a VSP Material Order
    • - Select "Medically Necessary" when entering the contact lens order
  • • Verify eligibility and obtain prior authorization if required
  • • Include ICD-10 diagnosis code supporting medical necessity
  • • Use appropriate CPT fitting codes (92071, 92072, 92310–92313)
  • • Use appropriate HCPCS material codes:
    • - V2531 – Scleral lenses
    • - V2530 – Hybrid lenses
    • - V2500–V2599 – Contact lens materials
  • • Document visual acuity with and without correction
  • • Include chart notes supporting why contact lenses are medically necessary
  • • Include keratometry/refraction findings when applicable

Coverage Details

  • • VSP medically necessary contact lenses are typically processed under medical necessity benefits
  • • Coverage and authorization requirements vary by plan
  • • Some plans may cover the fitting and materials separately
  • • Using a VSP network lab is preferred for streamlined claim processing
  • • Out-of-network lab claims may require manual submission

Important Note

Do NOT bill routine vision contact lens fitting codes (S0500, S0592) for medically necessary contact lenses.

Use only appropriate CPT and HCPCS medical billing codes. Claims may reject if medical necessity documentation is incomplete or unsupported.

EyeMed

2026 Billing Requirements

  • • REQUIRED: Submit the EyeMed Medically Necessary Contact Lens Claim Form for specialized lenses
  • • Form must be submitted for qualifying conditions:
    • - Keratoconus
    • - Anisometropia ≥3D
    • - High ametropia ≥10D
  • • Include specific diagnostic codes supporting medical necessity
  • • Include comprehensive documentation in medical records
  • • Authorization must be obtained prior to dispensing

Coverage Details (2026)

  • • Paid in full ($0 copay) after authorization
  • • Coverage ranges from $700 to $5,800 depending on the plan
  • • Covers both fitting fees and contact lens materials
  • • Patient's EyeMed vision benefit remains available for routine care
  • • Authorization requirements and coverage amounts vary by specific plan design

Process

  1. Verify patient eligibility and plan coverage for medically necessary contacts
  2. Complete EyeMed Medically Necessary Contact Lens Claim Form
  3. Submit form with appropriate CPT and ICD-10 diagnostic codes
  4. Obtain authorization before dispensing lenses
  5. Document that contacts are medically necessary, not cosmetic

Download Required Form

Download the EyeMed Medically Necessary Contact Lens Claim Form to submit with your billing:

Download EyeMed MNCL Claim Form

Key Difference

Unlike VSP, EyeMed does not have a medical necessity pathway. You must bill the patient's medical insurance directly.

Spectera (UnitedHealthcare Vision)

How Spectera Handles Medical Contacts

  • • Spectera does process medically necessary contact lens claims through the vision plan
  • • No prior authorization is required
  • • Contact lens material codes (V2500–V2599) are billed through Spectera
  • • Spectera vision benefits remain available for routine vision services (separate from medical contact billing)

Step-by-Step Billing Process

  1. Verify the patient has Spectera vision coverage
  2. Bill using CMS-1500 claim form with Place of Service 11
  3. Use appropriate CPT fitting codes (92310–92314, 92071)
  4. Include HCPCS material codes for contact lens supplies (V2500–V2599)
  5. Attach supporting ICD-10 diagnosis codes (H18.6xx for keratoconus, etc.)
  6. Include modifier -25 if billing E/M service on same day as fitting
  7. No prior authorization needed — submit claim directly to Spectera

Where to Submit Claims

  • • Submit to: Spectera (UnitedHealthcare Vision)
  • • Payer ID: 87726
  • • Portal: UHC Provider Portal (uhcprovider.com)
  • • For UMR-administered plans, use Payer ID: 39026

Documentation Requirements

  • • Visual acuity with current spectacles vs. contact lenses
  • • Slit lamp examination findings
  • • Topography/keratometry readings when applicable
  • • Clear explanation of why spectacles are inadequate
  • • Example: "BCVA improved from 20/60 with spectacles to 20/25 with GP contact lenses"

Important Notes

  • • No prior authorization is required — submit claims directly to Spectera
  • • Patient can still use their Spectera vision benefit for routine eye exams and glasses
  • • Ensure documentation clearly supports medical necessity to avoid claim denials

Superior Vision

Billing Requirements

  • • Submit medical claims through patient's medical insurance carrier
  • • Superior vision plans do not typically process medical necessity claims
  • • Use CPT codes with supporting ICD-10 diagnosis
  • • Include detailed clinical notes in chart

Process Overview

  1. Verify patient has medical insurance coverage
  2. Bill medical insurance with appropriate codes
  3. Patient can still use Superior vision benefit for routine services
  4. Keep thorough documentation of medical necessity

Important

Superior Vision operates similarly to EyeMed - medical necessity claims must go through the patient's medical insurance, not the vision plan.

General Billing Tips for All Plans

Documentation Best Practices

  • • Record best corrected visual acuity with spectacles
  • • Record visual acuity achieved with contact lenses
  • • Document improvement (e.g., "BCVA improved from 20/60 to 20/25")
  • • Explain functional limitations without contacts
  • • Include slit lamp findings and topography when applicable
  • • Note that patient requires contacts for daily activities

Common Modifiers

  • • -25 - Significant, separately identifiable E/M service on same day
  • • -TC - Technical component (for 92071 in some cases)
  • • -LT/-RT - Left/Right eye (when applicable)
  • • -52 - Reduced services (rarely used)

Common Denial Reasons

  • • Insufficient documentation of medical necessity
  • • Wrong claim form (vision form instead of CMS-1500)
  • • Missing or incorrect diagnosis codes
  • • Failure to show spectacles are inadequate
  • • Billing too frequently (exceeding annual limits)
  • • Missing prior authorization when required