Does Medicare Cover Keratoconus?

Keratoconus affects one out of every 2,000 individuals, according to Johns Hopkins Medicine. The condition occurs when the cornea thins and develops textural changes along its surface. If your doctor has diagnosed you with keratoconus, your vision is likely to decline over time, and you may be at risk for blindness. Although there isn't a cure for the disease, treatments can slow the progression, and some are covered by Medicare.

Does Medicare Cover Keratoconus?

Medicare is likely to cover some expenses related to the diagnosis and treatment of keratoconus but may not cover others. Typically, doctors begin to diagnose keratoconus during slit lamp examinations performed as a part of routine visits. Original Medicare generally doesn't cover this service, as it falls under vision care.

If your doctor suspects that you have keratoconus, they will likely create a map of your cornea through imaging called corneal topography. Medicare Part B typically covers computerized corneal topography for keratoconus when a participating medical provider deems that the test is medically necessary.

A test that measures the thickness of the cornea called pachymetry may also be necessary to fully diagnose keratoconus. Medicare does cover this test for some conditions, such as glaucoma; however, the guidelines don't explicitly state that keratoconus is a covered condition. As a result, your Medicare Part B plan may not cover the test.

Does Medicare Cover Eyeglasses for Keratoconus?

Often, doctors begin treating keratoconus with prescription eyeglasses. Normally, Medicare treats eyeglasses as a non-covered expense. Exceptions are made for people who are undergoing cataract surgery, but no carve-out exists for people who need eyewear for keratoconus. Your Medicare Part B plan might cover the expense if your doctor writes a letter explaining why the glasses are medically necessary, but you're not guaranteed coverage.

Does Medicare Cover Scleral Lenses for Keratoconus?

Keratoconus often progresses to the point where eyeglasses alone aren't effective at correcting vision. At this point, doctors may prescribe large hard contact lenses called scleral lenses. These lenses flatten out the cornea to help you see better. Under Medicare, contact lenses are treated like eyeglasses and are typically not covered. Your doctor might be able to obtain an exception by writing a letter that explains why scleral lenses are medically necessary.

Does Medicare Cover Corneal Cross-Linking for Keratoconus?

For intermediate-stage keratoconus, doctors may use corneal collagen cross-linking or CXL as a treatment. During this in-office procedure, a doctor applies vitamin B solution and shines ultraviolet light into your eye for up to 30 minutes. Research shows that this treatment may help to stimulate the production of collagen to increase the thickness of the cornea.

The FDA approved CXL as a treatment for keratoconus in 2016. Prior to that time, most Medicare plans wouldn't cover CXL because it was considered experimental. Despite FDA approval for the treatment, Medicare has yet to publish guidelines regarding payment for CXL, leaving the choice about whether to cover the therapy up to Part B providers. 

Does Medicare Cover Corneal Rings for Keratoconus?

When keratoconus progresses to advanced stages, corneal rings are sometimes used to treat the condition. These small C-shaped plastic rings sit over the cornea, exerting pressure that flattens the surface to promote clearer vision. The journal Ophthalmology Management reports that Medicare Part B may sometimes cover corneal rings. When plans do pay for the expense, doctors must verify that they are medically necessary, and the expense must be coded properly.

Does Medicare Cover Corneal Transplant for Keratoconus?

If all other treatments fail, your doctor may suggest a corneal transplant. During this surgical procedure, your damaged cornea is removed and replaced with a healthy donor cornea. Medicare often covers corneal transplants that are deemed medically necessary and performed in an approved facility. Usually, the coverage falls under Medicare Part B.

If you need to be hospitalized after the procedure, Medicare Part A is likely to cover the cost of the stay. You'll first need to satisfy your deductible, and you may be assessed coinsurance.

How Much Will I Pay for Covered Keratoconus Expenses Under Medicare Part B?

If Medicare Part B covers any diagnostic test or treatment for keratoconus, your plan will typically pay for 80% of the cost, leaving you responsible for the 20% that remains. Medicare supplement (Medigap) plans may help you pay for all or some of the out-of-pocket costs. Before Medicare Part B pays for expenses, you must satisfy your deductible. Your payment of monthly premiums must also be up to date.

Will Medicare Advantage Plans Cover Keratoconus?

Medicare Advantage Plans (Medicare Part C) must cover at least as much as Original Medicare does, making it likely that your plan will pay for corneal topography and corneal transplants under the same guidelines. In addition, some plans have basic vision coverage that may help you pay for eyeglasses and scleral lenses. Other diagnostic tests or treatments may or may not be covered, depending on the terms of your plan. You'll usually have to satisfy a deductible and pay coinsurance or a copay for covered expenses.

How Can I Find Out If Care for Keratoconus Is Covered by My Plan?

Contact the provider of your Medicare Part B or Medicare Advantage Plan for detailed information about which keratoconus treatment options are covered by your plan. Your doctor's office staff may also wish to contact your Medicare plan to find out how to properly code your claim to increase the likelihood of approval.