or Post-Transplant Corneal Surgery
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; and
The member must be intolerant of glasses or contact lenses.
Phototherapeutic Keratectomy (S0812)
Phototherapeutic keratectomy (PTK) is considered medically necessary for members
with any of the following corneal conditions. Preauthorization is
Superficial corneal dystrophy (including granular, lattice, and Reis-Bückler`s
Epithelial membrane dystrophy; or
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); or
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.
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.
considered experimental and investigational for treatment of infectious
keratitis because it has not been shown to be safe and effective for this
standard benefit plans exclude coverage of “radial keratotomy, including related
procedures designed to surgically correct refractive errors.” Traditional
benefit plans generally exclude coverage for services “for or related to any eye
surgery mainly to correct refractive errors.” These exclusions apply to radial
keratotomy (RK), astigmatic keratotomy, photorefractive keratectomy (PRK),
Photoastigmatic keratectomy (PARK), laser-in-situ Keratomileusis (LASIK),
Keratomileusis, Epikeratophakia implementation of intrastromal corneal ring
segments and other refractive surgical procedures.
that do not have a specific contractual exclusion of refractive surgery,
refractive surgery is considered investigational or not medically necessary, as
is outlined below.
surgical procedures are considered not medically necessary, because spectacles
or contact lenses have been shown to provide more accurate corrections of
refractive errors than refractive surgery. Although the efficacy of refractive
surgery is improving, the accuracy and precision of the refractive corrections
achieved is substantially less than that which can be achieved with spectacle
correction. In a randomized prospective study of laser in situ Keratomileusis
(LASIK) and photorefractive keratectomy (PRK) for myopia, Hersh et al. (1998)
reported that 29.4% of PRK patients and 27.1% of LASIK patients had refractive
corrections within 0.5 diopters of attempted correction at six months after
surgery. In comparison, over 99% of patients who are corrected with glasses or
contact lenses achieve refractive corrections within 0.5 diopters of normal
vision (Waring, 1990).
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.”
keratotomy (RK) (65771)
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.
keratotomy (AK) (65772)
(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
Keratomileusis (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.
Keratomileusis (ALK) (65760)
where 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
Epikeratoplasty (Epikeratophakia) (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.
Keratoplasty (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.
Keratoplasty (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.
Photorefractive Keratectomy (PRK)
(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.
Corneal Ring Segments (INTACS)
(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) require preauthorization.
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.”
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
Lens Implants (clear lens extraction)
(aphakic intraocular lenses (IOLs)) are considered not medically
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 (65756):
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:
Endothelial corneal dystrophy and other posterdystrophiesl dystrophies;
Mechanical complications due to corneal graft or ocular lens prostheses;
Rupture of Descemet`s membrane.
Keratoplasty 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.
Keratoprosthesis requires preauthorization. This procedure is covered
for individuals where:
The cornea is severely opaque and vascularized; AND
The patient has had 2 or more prior failed corneal transplants
Treatment should be restricted to centers experienced in treatment this
condition and staffed by surgeons adequately trained in techniques
addressing implantation of this device.
other use is considered experimental.
Codes Used In This BI:
65710 Corneal transplant
65730 Corneal transplant
65750 Corneal transplant
65755 Corneal transplant
65756 Corneal trnspl endothelial
65757 Prep corneal endo allograft
65760 Revision of cornea
65765 Revision of cornea
65767 Corneal tissue transplant
65770 Revise cornea with implant
65771 Radial keratotomy
65772 Correction of astigmatism
65775 Correction of astigmatism
S0800 Laser in situ Keratomileusis
S0810 Photorefractive keratectomy
S0812 Phototherap keratect
0099T Refractive Surgery (deleted 1/1/16)
65785 Implantation of intrastromal corneal ring segments (new code 1/1/16)