Post-Transplant Corneal Surgery
Correction of surgically
induced astigmatism with a corneal relaxing incision or corneal wedge resection
(65772, 65775) is considered medically necessary if the member had previous
penetrating keratoplasty (corneal transplant) within the past 60 months or
cataract surgery within the last 36 months and
both of the
following criteria are met:
The degree of astigmatism must be 3.00 diopters or greater;
The member must be intolerant of glasses or contact lenses.
Phototherapeutic keratectomy (PTK) is considered medically necessary for members
any of the following corneal
conditions. Preauthorization is required.
Superficial corneal dystrophy (including granular, lattice, and Reis-Bückler`s
Epithelial membrane dystrophy;
Irregular corneal surfaces due to Salzmann`s nodular degeneration or keratoconus
Corneal scars and opacities (including post-traumatic, post-infectious,
post-surgical, and secondary to pathology);
Recurrent corneal erosions when more conservative measures (e.g., lubricants,
hypertonic saline, patching, bandage contact lenses, gentle debridement of
severely aberrant epithelium) have failed to halt the erosions.
Phototherapeutic keratectomy (PTK) should not be confused with photorefractive
keratectomy (PRK). Although technically the same procedure, PTK is used for the
correction of particular corneal diseases, whereas PRK involves use of the
excimer laser for correction of refractive errors (e.g., myopia, hyperopia,
astigmatism, and presbyopia) in persons with otherwise non-diseased corneas.
If used unilaterally PTK
will induce a certain degree of anisometropia since it induces a shift in
refraction to the hyperopic (farsighted) side. This hyperopic shift might be
welcomed in Myopes but may be problematic for emmetropes or low Myopes.
PTK is considered
experimental and investigational for treatment of infectious keratitis because
it has not been shown to be safe and effective for this indication.
benefit plans and traditional benefit plans exclude coverage of “ any surgery
mainly to correct refractive errors.” These exclusions apply to radial
keratotomy (RK), astigmatic keratotomy (AK), photorefractive keratectomy (PRK),
Photoastigmatic keratectomy (PARK), laser-in-situ Keratomileusis (LASIK),
Keratomileusis, Epikeratophakia, intrastromal corneal ring segments, and other
refractive surgical procedures.
For plans that
do not have a specific contractual exclusion of refractive
surgery, refractive surgery is considered not medically necessary.
Spectacles or contact lenses have been shown to provide more accurate
corrections of refractive errors than can refractive surgery.
Although the safety of
refractive surgical procedures is improving, these procedures are associated
with significant risks of degradation of best corrected visual acuity, as well
as glare, induced regular or irregular astigmatism, regression of effect, visual
aberations (including transient or permanent glare or starburst/halo effect),
and decreased contrast sensitivity. According to the AAO Preferred Practice
Pattern on Refractive Errors, “[s]pectacles are the simplest and safest means of
correcting a refractive error.”
Radial keratotomy (RK)
involves the use of radial incisions in the cornea to correct mild to moderate
Radial keratotomy is not considered medically necessary for treatment of myopia
ranging from -2.00 to -8.00 diopters because this refractive error can be
corrected satisfactorily with eyeglasses or contact lenses.
Radial keratotomy is considered investigational for treatment of myopia greater
than -8.00 diopters and it is also considered investigational for treatment of
all other refractive errors.
(arcuate incision, corneal wedge resection) is a refractive surgical procedure
similar to RK that is used to reduce astigmatism.
Astigmatic keratotomy may be covered when performed for the correction of
surgically induced astigmatism following medically indicated cataract removal or
corneal transplant surgery (see criteria above).
Astigmatic keratotomy is considered investigational for treatment of all other
(LASIK) (65760 or S0800)
is a type of laser surgery of the cornea to correct refractive errors, in which
a slice of the patient`s cornea is removed, shaped to the desired curvature with
an excimer laser, and then sutured back to the remaining cornea.
Laser-in-situ Keratomileusis is considered not medically necessary for treatment
of myopia between -1.0 and -15.0 diopters, with or without astigmatism up to 5.0
diopters, because this can be corrected satisfactorily with eyeglasses or
Laser-in-situ Keratomileusis is also considered not medically necessary for
treatment of hyperopia up to + 6.0 diopters with or without astigmatism up to 5
Laser-in-situ Keratomileusis is considered investigational for treatment of
myopia greater than -15.0 diopters or hyperopia greater than + 6.0 diopters, for
treatment of persons with astigmatism greater than 5.0 diopters, and for all
other refractive errors.
the cornea is shaped with a microkeratome rather than with a laser,
ALK is considered investigational for treatment of all refractive errors. In
current clinical practice, ALK is being replaced by laser in situ
(65767) is a
refractive surgical procedure that involves placement of a pre-carved donor
corneal lens on the surface of a patient`s eye. Epikeratoplasty
(Epikeratophakia) requires preauthorization.
Epikeratophakia may be covered for the treatment of childhood aphakia since
contact lenses are difficult for children to use and intraocular lens implants
may result in long-term complications in children.
May also be covered when used on scarred corneas and corneas affected with
May be covered in the treatment of adult aphakia, where reentering the eye could
affect outcome (e.g., vitreous in the anterior chamber, history of uveitis,
disorganized anterior chamber that cannot support an intraocular lens,
significant corneal endothelial disease, or gross corneal irregularity after
This procedure is considered investigational for correction of refractive errors
and for all other cases of adult aphakia.
involves implantation of a donor cornea within the corneal stroma to modify its
Keratophakia is considered investigational for correction of refractive errors.
(non-penetrating Keratoplasty) (65710)
is a corneal transplant
procedure in which a partial thickness of the cornea is removed and the diseased
tissue is replaced with a partial-thickness donor cornea. The donor eye is
prepared by making a partial thickness trephine incision in the cornea and
dissecting free the lamellar button. Lamellar Keratoplasty (non-penetrating
Keratoplasty) requires preauthorization.
This procedure may be covered for a number of corneal diseases, including
scarring, edema, thinning, distortion, dystrophies, degenerations, and
Utilization has been very low on this procedure. We will pay and audit claims
and clinical records as indicated.
It is considered investigational when performed solely to correct astigmatism
and other refractive errors.
(PK) (Corneal Transplantation, Perforating Keratoplasty)
(65730, 65750, 65755) is a corneal
transplant procedure involving replacement of the full thickness of the cornea
with donor cornea, but retaining the peripheral cornea.
PKs are covered to improve poor visual acuity caused by an opaque cornea.
Penetrating Keratoplasty is covered when used to remove active corneal disease,
such as persistent severe bacterial, fungal, or amebic inflammation of the
cornea (keratitis) after appropriate antibiotic therapy.
Penetrating Keratoplasty has also been performed to restore altered corneal
structure or to prevent loss of the globe that has been punctured.
PK is covered for bullous keratopathy, keratoconus, corneal scar with opacity,
keratitis, corneal transplant rejection, Fuch`s dystrophy, corneal degeneration,
other corneal dystrophies, corneal edema, and herpes simplex keratitis.
Historically, utilization of this procedure has been rare. We will continue to
cover without preauthorization, but will audit claims and clinical records as
Penetrating Keratoplasty is considered investigational when performed solely to
correct astigmatism or other refractive errors.
(S0810) is a refractive surgical
procedure involving the reshaping of the surface of the cornea with an excimer
laser to correct mild-to-moderate myopia. Photoastigmatic keratectomy (PARK or
PRK-A) is a refractive surgical procedure to correct myopia with astigmatism.
These procedures are considered not medically necessary for patients with
hyperopia of up to 6.0 diopters and myopia of up to -10.0 diopters, with or
without astigmatism up to 4.0 diopters, because the refractive corrections
achieved with PRK and PARK are less precise than that achieved by eyeglasses or
Photorefractive keratectomy and PARK are considered investigational for patients
with hyperopia greater than 6.0 diopters, myopia greater than -10.0 diopters,
astigmatism greater than 4.0 diopters, and for all other refractive errors.
Intrastromal Corneal Ring
(65785) (Addition Technology,
Sunnyvale, CA) have been approved by the FDA for adults with mild myopia (from
-1.0 to -3.0 diopters) that have less than 1 diopter of astigmatism.
Intrastromal corneal ring segments. Intrastromal corneal ring segments (INTACS)
considered not medically necessary
for patients with mild myopia.
INTACS are considered experimental and investigational for children, for
patients with moderate to severe myopia (greater than -3.0 diopters), for
patients with more than 1 diopter of astigmatism, and for hyperopia.
Intrastromal corneal ring segments are considered medically necessary for
reduction or elimination of myopia or astigmatism in persons with keratoconus
who are no longer able to achieve adequate vision using contact lenses or
spectacles and for whom corneal transplant is the only remaining option.
involves the application of radiofrequency thermal energy to increase the
curvature of the cornea and thereby reduce hyperopia. Conductive keratoplasty
using the ViewPoint CK System (Refractec Inc., Irvine, CA) has been approved by
the FDA for treatment of patients who are at least 40 years of age, who have
mild to moderate hyperopia (0.75 D to 3.25 D), who have 0.75 D or less
astigmatism, and whose eyesight has changed very little over the previous 12
months (as demonstrated by a change of less than 0.50 D in refraction).
Conductive Keratoplasty is considered not medically necessary for the above
Conductive Keratoplasty is considered experimental and investigational for all
involves the application of sequentially flatter hard contact lenses to flatten
the cornea and thereby reduce myopic refractive error. It is considered
investigational. The AAO Preferred Practice Pattern on Refractive Errors states
that “Attempts to predict which patients will respond to orthokeratology based
on ocular biomechanical or biometric parameters have not been successful. The
effects of orthokeratology have been unpredictable and poorly controlled. … This
approach is not recommended.”
Scleral Expansion Surgery
is considered experimental and investigational for presbyopia. Scleral expansion
surgery involves making small incisions in the eye and inserting bands to
stretch the part of the sclera that lies beneath the ciliary muscles that
Intraocular Lens Implants
(clear lens extraction)
(aphakic intraocular lenses (IOLs)) are considered
necessary for correction of presbyopia, hyperopia, and myopia because these
refractive errors can be corrected satisfactorily with eyeglasses or contact
(without lens extraction) (phakic intraocular lenses (IOLs) (e.g., Artisan lens,
Verisye lens) has been approved by the FDA for adult patients who have myopia
ranging from -5 to -20 diopters with less than or equal to 2.5 diopter of
astigmatism. Implantable contact lenses are considered not medically necessary
for myopia ranging from -5 to -20 diopters in persons with 2.5 diopters of
astigmatism or less because external contact lenses or eyeglasses produce
equivalent therapeutic results for treatment of refractive errors. Implantable
contact lenses are considered experimental and investigational for other
Endothelial Keratoplasty (Descemet`s stripping endothelial Keratoplasty (DSEK),
Descemet`s stripping automated endothelial Keratoplasty (DSAEK), and Descemet`s
membrane endothelial Keratoplasty (DLEK) require preauthorization.
These procedures are considered medically necessary for the following
indications in persons with endothelial failure and otherwise healthy corneas:
corneal dystrophy and other posterior dystrophies;
complications due to corneal graft or ocular lens prostheses;
procedures are considered experimental and investigational for conditions with
concurrent endothelial disease and anterior corneal disease, including anterior
corneal dystrophies, anterior corneal scars from trauma or prior infection,
ectatic conditions of the cornea such as keratoconus, pellucid marginal
degeneration and ectasia after previous laser vision correction surgery, and for
all other indications.
requires preauthorization. This procedure is covered for individuals
The cornea is severely opaque and vascularized; AND
The patient has had 2 or more prior failed corneal transplants
be restricted to centers experienced in treatment this condition and
staffed by surgeons adequately trained in techniques addressing
implantation of this device.
Any other use is
Used In This BI:
Corneal trnspl endothelial
corneal endo allograft
Revision of cornea
Revision of cornea
Corneal tissue transplant
Revise cornea with implant
Correction of astigmatism
Correction of astigmatism
in situ Keratomileusis
Refractive Surgery (deleted 1/1/16)
Implantation of intrastromal corneal ring segments (new code 1/1/16)