Pediatric and Teen CL Care

Getting Reimbursed

By Christine W. Sindt, OD, FAAO

Colleagues frequently ask me how to get reimbursement for pediatric medically necessary contact lenses. I have used two templates with good results. One is an Insurance Reimbursement Request form, which is available for download by clicking this link.

Letter to Insurance Company

In some cases, it is appropriate to petition an insurance company for a policy change so each individual lens does not require a review of coverage. Here is an example for a request for coverage for pediatric aphakia.

To whom it may concern:

This is a request for review of coverage for (Patient name) pediatric aphakic (ICD-9 379.31) contact lenses. This letter is intended to outline the necessity of contact lenses, the time and services involved in fitting the lenses, cost of the lenses, and the necessity of backup contact lenses. Pediatric aphakia cannot be compared to adult aphakia.

A child is not born being able to see. Vision develops as an image forms in the eye and is transmitted to the brain. If the brain is denied an image, pathways that allow the brain to process the image are not formed. This is called amblyopia (ICD-9 Code 368.00). There is a critical period in a child's life in which these pathways can be formed. This time is most critical during the child's first year of life. After the first year it becomes increasingly difficult to improve vision.

When a child is diagnosed with a cataract (ICD-9 Code 743.30), it must be removed immediately if it is hindering vision development. However, without a lens inside the eye, the light will not focus and form an image on the retina. Spectacles or a contact lens must be fit quickly so the vision pathway to the brain can start to form. Spectacles, however, can cause image distortion, prismatic effects, anisometropia (ICD-9 Code 367.31), and aniseikonia, resulting in a less than perfect image. All of these effects are eliminated by using contact lenses. A contact lens acts as if it were part of the eye; wherever a child looks, he will be looking through the lens center. Spectacles are not possible in the case of unilateral aphakia because of the image size difference that aniseikonia (ICD-9 code 367.32) induces.

Unlike an adult aphake, a child's eye is continuing to grow. As the eye length increases, the power needed to correct the child's vision will decrease. This causes frequent changes in a child's contact lens. It is necessary to follow a child with frequent examinations to monitor that child's visual development. In many cases, we need to change a child's lens more quickly than we are able to obtain prior consent.

In some cases, it may take two or more weeks to get a contact lens from a manufacturer. Because of the time delay and possible vision loss, we require the parents to keep a backup pair of contact lenses at home.

An infant is seen every one to two weeks during the initial three months of fitting. Then the baby is seen every month for the rest of the first year. Infants typically require a change in lens fit at 6 to 8 weeks old, 6 to 9 months old, and around 1 year old. After one year a child is seen less frequently, every two to three months, and requires fewer changes. The average child goes through eight lenses per eye during the first year of life and four lenses per eye thereafter, including fit changes, loss, and breakage.

The use of contact lenses in pediatric aphakia is a true medical necessity. These lenses are prosthetic devices, replacing the lens of the eye. They correct vision beyond that which is obtainable with spectacles. However, it is necessary to monitor the fit and make changes as the eye grows to ensure health and optimum development of the visual pathway.

Sincerely, (Your name) CLS

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Dr. Sindt is a clinical associate professor of ophthalmology and director of the contact lens service at the University of Iowa Department of Ophthalmology and Visual Sciences. She is also the 2010-2011 Chair of the AOA Cornea and Contact Lens Council. She is a consultant or advisor to Alcon, Ciba Vision, and Vistakon and has received research funds from Alcon. You can reach her at christine-sindt@uiowa.edu.