Payment may be made for the Boston Scleral Lens (BSL)(S0515) when the following criteria are met:

1. The patient has severe ocular surface disease resulting in ocular pain and photophobia, and
2. Other treatment has been tried and failed.

Severe ocular surface disease includes the following conditions:

• Corneal stem cell deficiencies resulting from Stevens-Johnson syndrome (695.1) and toxic epidermal necrolysis (TEN)(695.1), chemical injuries (940.2, 940.3, 940.4) and thermal injuries, ocular pemphigoid (694.61), or aniridia (743.45).
• Keratitis sicca (710.2) due to disorders of the lacrimal gland (e.g., Sjogren’s syndrome, graft vs. host disease, irradiation, surgery) and meibomian gland deficiency.
• Neurotrophic corneas resulting from herpes simplex/zoster keratitis, congenital corneal anesthesia (dysautonomia), diabetes, acoustic neuroma surgery, trigeminal ganglionectomy, or trigeminal rhizotomy.
• Persistent non-infectious corneal ulcers and epithelial defects associated with stem cell deficient and neurotrophic corneas.

In general, the Boston Scleral Lens is indicated in corneal disorders for which tarsorrhaphy would be considered.

NOTE:

When used solely for the correction of refractive errors, the Boston Scleral Lens is not covered under the member’s medical surgical benefits. A participating, preferred, or network provider can bill the member for the denied service.

Coverage for Prosthetics is determined according to individual or group customer benefits.

Description

The Boston Scleral Lens is a specially designed fluid-ventilated gas-permeable contact lens that provides a non-surgical means of restoring vision in eyes affected by corneal disorders. The lens is about the size of a quarter. It rests on the insensitive white part of the eye (the sclera) and arches over the damaged cornea, thereby creating a space that is filled with soothing, artificial tears. This fluid reservoir masks the distortion created by the irregular surface of diseased corneas to improve vision. It also functions as a unique liquid bandage that protects the corneal surface from the desiccating effects of exposure to air and the friction of blinking and significantly reduces the intensity of ocular pain and photophobia associated with ocular surface disease. In addition, it facilitates the healing of persistent epithelial defects. The lens is made of highly oxygen-porous plastic that allows the cornea to breathe.

The Boston Scleral Lens is intended to benefit patients by: 1) masking abnormal corneal astigmatism when traditional rigid gas-permeable (RGP) corneal contact lenses fail or are contraindicated and 2) managing severe ocular surface disease.

At this time, the Boston Scleral Lens is available only at the Boston Foundation for Sight. New patients are not accepted without a written referral and clinical information sufficient to enable the Foundation to evaluate the potential of the lens to offer them a significant benefit. 

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

PRN References

12/2004, Boston Scleral Lens

Gas-permeable Scleral Contact Lens Therapy in Ocular Surface Disease, American Journal of Ophthalmology, Vol. 130, No. 1, July 2000

Treatment of Persistent Corneal Epithelial Defect with Extended Wear of a Fluid-ventilated Gas-permeable Scleral Contact Lens, American Journal of Ophthalmology, Vol. 130, No. 1, July 2000

The Boston Scleral Lens in the management of severe ocular surface disease, Ophthalmology Clinics of North America, Vol. 16, No. 1, March 2003