Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

Corneal Pachymetry is covered, subject to medical necessity. Corneal Pachymetry is a non-invasive ultrasonic technique for measuring corneal thickness.

1. QualChoice/QCA considers ultrasound corneal Pachymetry medically necessary for the following indications:

1. Persons with glaucoma or elevated intraocular pressure (elevated intraocular pressure greater than or equal to 24 mm Hg)(H40.001 - H40.9) (testing is considered medically necessary once per lifetime); or
2. Corneal transplant (penetrating Keratoplasty)(65710 - 65755) (pre- and post-operative evaluation); or
3. Evaluation of corneal rejection (T86.840) post penetrating Keratoplasty; or
4. Corneal edema (H18.20 - H18.239); or
5. Fuch’s endothelial dystrophy (H18.51); or
6. Bullous keratopathy (H18.10 - H18.13); or
7. Posterior polymorphous dystrophy (H18.59); or
8. Corneal refractive surgery (65760 - 65775)(pre- and post-operative evaluation)*; or
9. Evaluation of complications of corneal refractive surgery (65760 - 65775) (once).*
1. Corneal Pachymetry is not considered medically necessary prior to cataract surgery unless corneal disease is documented.
2. Corneal Pachymetry is considered experimental and investigational as a screening test for glaucoma for persons without signs or symptoms of glaucoma or elevated intraocular pressure.

*Note: Most QualChoice/QCA benefit plans exclude coverage of refractive surgery. Please check benefit plan descriptions for details. Corneal Pachymetry for evaluation of persons undergoing corneal refractive surgery is excluded from coverage under plans with these provisions.

*Note: For purposes of this policy, only the ultrasound method of corneal Pachymetry is considered.

Codes Used In This BI:

76514           Echo Exam of Eye

Repeat testing for corneal diseases and injuries (indications B through G) is not considered medically necessary if performed more frequently than once every 6 months.

1.     American Academy of Ophthalmology Refractive Errors Panel. Refractive errors. San Francisco (CA): American Academy of Ophthalmology; 2002.

2.     Canadian Ophthalmological Society. Practice guidelines for refractive surgery. Policy Statements and Guidelines. Canadian Ophthalmological Society; June 2000.

3.     American Academy of Ophthalmology Glaucoma Panel. Primary open-angle glaucoma suspect. San Francisco (CA): American Academy of Ophthalmology; 2002 Oct.

4.     Palmberg P. Answers from the ocular hypertension treatment study. Archive Ophthalmol. 2002; 120 (6):829-830.

5.     Doughty MJ, Zaman ML. Human corneal thickness and its impact on intraocular pressure measures: A review and meta-analysis approach. Surg Ophthalmol. 2000; 44(5):367-408.

6.     Whitacre MM, Stein RA, Hassanein K. The effect of corneal thickness on application tonometry. Am J Ophthalmol. 1993; 115:592-596.

7.      Gordon MO, Beiser JA, Brandt JD, et al. The Ocular Hypertension Treatment Study: Baseline factors that predict the onset of primary open angle glaucoma. Arch Ophthalmol. 2002; 120(6):714-719.

Unless indicated otherwise, this policy applies to all QualChoice/QCA /QCA plans, in the absence of a stated exclusion.  Consult individual plan sponsor benefit descriptions for self-insured plans.  In the event of a discrepancy between this policy and a self-insured customer’s benefit description, the benefits plan will be followed.  Applicable state mandates will be followed with respect to self-funded non-ERISA plans and fully insured plans.  Federal mandates will apply to all plans.