Medical Policy
Effective Date:02/01/2006 Title:Corneal Graft with Amniotic Membrane Transplant for Eye
Revision Date: Document:BI139:00
CPT Code(s):65780
Public Statement

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.

In certain conditions the normal rapid repair of corneal defects is impaired or absent. This allows abnormal cells to grow onto the cornea.

 

Amniotic membrane transplant (AMT) is used to help repair the corneal surface when other therapies are not effective.

 

AMT requires pre-authorization.
Medical Statement

Preserved human amniotic membrane transplantation (AMT) is considered medically necessary for ocular surface reconstruction in members with limbal deficiency (hypofunction or total loss of stem cells) refractory to conventional treatment when the member has any of the following conditions:  Total loss of stem cells: (one eye involvement only)

·       Chemical / thermal injuries of the ocular surface

·       Stevens-Johnson syndrome

·       Multiple surgeries or cryotherapies to the limbal region

·       Contact lens-induced keratopathy or toxic effects from lens-cleaning solutions.

Hypofunction of stem cells: (one or both eyes can be involved)

  • Aniridia (hereditary)
  • Keratitis associated with multiple endocrine deficiency (hereditary)
  • Neurotrophic keratopathy (neuronal or ischemic)
  • Chronic limbitis
  • Peripheral corneal ulcerative keratitis
  • Pterygium and pseudopterygium.

 

Codes Used In This BI:

65780           Ocular reconst transplant
Limits
Intentially left empty
Reference
  1. Tsubota K, Satake Y, Kaido M, et al. Treatment of severe ocular-surface disorders with corneal epithelial stem-cell transplantation. N Engl J Med. 1999;340(22):1697-1703.
  2. Akpek EK, Foster CS. Limbal stem-cell transplantation. Int Ophthalmol Clin. 1999;39(1):71-82.
  3. Tsai RJ, Li LM, Chen JK. Reconstruction of damaged corneas by transplantation of autologous limbal epithelial cells. N Engl J Med. 2000;343(2):86-93.
  4. Meller D, Maskin SL, Pires RT, et al. Amniotic membrane transplantation for symptomatic conjunctivochalasis refractory to medical treatments. Cornea. 2000;19(6):796-803.
  5. Koizumi N, Inatomi T, Suzuki T, et al. Cultivated corneal epithelial stem cell transplantation in ocular surface disorders. Ophthalmology. 2001;108(9):1569-1574.
  6. Anderson DF, Ellies P, Pires RT, et al. Amniotic membrane transplantation for partial limbal stem cell deficiency. Br J Ophthalmol. 2001;85(5):567-575.
  7. Stoiber J, Muss WH, Pohla-Gubo G, et al. Histopathology of human corneas after amniotic membrane and limbal stem cell transplantation for severe chemical burn. Cornea. 2002;21(5):482-489.
  8. Lee C, Samuel M, Tan D. Surgical interventions for pterygium (Protocol for a Cochrane Review). In: The Cochrane Library, Issue 2, 2004. Chichester, UK: John Wiley & Sons, Ltd.
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.