Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Refractive Keratoplasty

Policy #:11.05.01e

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

MEDICALLY NECESSARY

Refractive keratoplasty is considered medically necessary and, therefore, covered when performed by corneal relaxing incision (Current Procedural Terminology [CPT] code 65772), corneal wedge resection (CPT code 65775), or conductive keratoplasty (CPT code 66999) for the correction of astigmatism resulting from trauma or previous eye surgery (e.g., cataract surgery, penetrating keratoplasty, etc).

The Boston (Dohlman-Doane) Keratoprothesis (Boston KPro) is considered medically necessary for the surgical treatment of corneal opacification in individuals who meet the following criteria:
  • Cadaveric corneal transplants have failed or have a very low likelihood of success.
  • The cornea is severely opaque and vascularized AND
  • Best-corrected visual acuity is 20/400 or less in the affected eye and 20/40 or less in the contralateral eye AND
  • No end-stage glaucoma or retinal detachment is present AND
  • The individual has one of the following indications:
    • History of 1 or more corneal transplant graft failures.
    • Stevens-Johnson syndrome.
    • Ocular cicatricial pemphigold.
    • Autoimmune conditions with rare ocular involvement.
    • Ocular chemical burns.
    • An ocular condition unlikely to respond favorably to primary corneal transplant surgery (eg., limbal stem cell compromise or postherpetic anesthesia).

Corneal collagen cross-linking using riboflavin and ultraviolet A is considered medically necessary and, therefore, covered when used as a treatment of progressive keratoconus or corneal ectasia after refractive surgery.

EXPERIMENTAL/INVESTIGATIONAL

All other uses for refractive keratoplasty are considered experimental/investigational and, therefore, not covered because their safety and/or effectiveness cannot be established by review of the available published peer-reviewed literature.

All other uses for corneal collagen cross-linking are considered experimental/investigational and, therefore, not covered because their safety and/or effectiveness cannot be established by review of the available published peer-reviewed literature.

Keratoprosthesis with any other device other than the Boston KPro is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

BENEFIT CONTRACT EXCLUSIONS

All other refractive keratoplasty procedures and related services performed for the correction of refractive defects (e.g., myopia, hyperopia, or astigmatism) in order to eliminate or reduce the need for prescription or corrective vision lenses are not covered by the Company because they are a benefit contract exclusion. Therefore, they are not eligible for reimbursement consideration.
  • For some of the Company's products, these services are a benefit option; therefore, individual member benefits must be verified.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, refractive keratoplasty is covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met. However, services that are identified in this policy as experimental/investigational are not eligible for coverage or reimbursement by the Company. Company benefit contracts may exclude the surgical treatment of myopia. Individual benefits must be verified, as coverage may vary between products and/or groups.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

The Boston KPro (Dohlman-Doane keratoprosthesis; Massachusetts Eye and Ear Infirmary) was approved by the U.S. Food and Drug Administration (FDA) through the premarket approval process on January 21, 1992 for use in patients with severe corneal opacity. The device is used when standard corneal transplant has failed or would be unlikely to succeed. There are 2 types of Boston KPro. Type I is used in eyes when eyelids, blink mechanism and tear film are intact. Type II is used with severe dry eye and in eyes with mucosal keratinization and obliteration of normal conjunctival fornices.

The ViewPoint® CK System was approved by the FDA on April 11, 2002.

In late 2011, the FDA awarded orphan drug status to Avedro for its formulation of riboflavin ophthalmic solution to be used in conjunction with the company's particular UVA irradiation system. In 2015, however, the FDA withdrew its approval citing a need for more data.

Riboflavin 5´-phosphate in 20% dextran ophthalmic solution (Photrexa Viscous®; Avedro) and riboflavin 5´-phosphate ophthalmic solution (Photrexa®; Avedro) were approved by the U.S. Food and Drug Administration (FDA) on April 15, 2016 for use with KXL System in corneal collagen cross-linking for the treatment of progressive keratoconus and corneal ectasia after refractive surgery.

BILLING GUIDELINES

There is no specific procedure code for conductive keratoplasty. When the procedure is performed for the correction of astigmatism resulting from trauma or previous eye surgery, providers should report the nonspecific Current Procedural Terminology (CPT) code 66999.

Description

The cornea is the part of the eye that helps focus light in order to create an image on the retina. It works in much the same way that the lens of a camera focuses light to create an image on film.

The bending and focusing of light by the cornea is known as refraction. When a refractive error occurs, it is usually because of imperfections in the shape of the cornea and/or the eye that cause the image on the retina to become out of focus (blurred) or distorted. Eye glasses or contact lenses are designed to compensate for the eye's imperfections.

Refractive keratoplasty is a generic term that includes surgical procedures that reshape the cornea to correct vision problems such as myopia (nearsightedness), hyperopia (farsightedness), and astigmatism (a distortion of the image on the retina caused by irregularities in the cornea or lens of the eye).

Refractive keratoplastic procedures include the following:
  • Corneal relaxing incisions (CRIs): A subset of astigmatic keratomy (AK) (the other subset is limbal relaxing incisions [LRIs]), in which partial thickness incisions are made at the corneal periphery for the treatment of corneal astigmatism.
  • Corneal wedge resection: A procedure performed to correct post-transplant--induced astigmatism. In this procedure, a wedge resection is designed to steepen the flattest corneal meridian by removing a wedge of corneal tissue and suturing the edges together.
  • Conductive keratoplasty (CK): Radiofrequency energy is applied to heat points around the edge of the cornea, thus shrinking and tightening the collagen in the eye and increasing the curvature of the eye over the cornea to correct hyperopia or astigmatism (i.e., the ViewPoint® CK System).
  • Epikeratoplasty: A donor cornea is applied to the anterior surface of the cornea from which the epithelium has been removed to correct hyperopia.
  • Keratomileusis: The front of the cornea is removed, frozen, reshaped, and stitched back onto the eye to correct myopia or hyperopia.
  • Keratophakia: A reshaped donor cornea is inserted in the eye to correct hyperopia.
  • Laser in situ keratomileusis (LASIK): LASIK is a laser procedure that permanently reshapes the inner layers of the cornea to correct myopia or hyperopia.
    • Wavefront-guided LASIK is an enhanced laser procedure in which data is translated into a mathematical formula that is programmed into the laser to create a computer-generated map that vaporizes corneal tissue to correct myopia or astigmatism (e.g., the LADARWave Customized Ablation System and the VISX CustomVue System).
  • Photorefractive keratectomy (PRK): An excimer laser is used to remove a thin layer of the cornea (epithelium) to correct or reduce astigmatism (eg, the LADARVision® System and the LASERScan LSX System).
  • Radial keratotomy (RK): Spoke-like slits are cut in the cornea to weaken and flatten the normally curved central portion to correct myopia.
    • Astigmatic keratotomy (AK), which is similar to RK, is performed to reduce astigmatism.
  • Collagen cross-linking of the cornea (CXL): Corneal collagen cross-linking (CXL) is a photochemical procedure that is approved by the Food and Drug Administration (FDA) for the treatment of progressive keratoconus and corneal ectasia. Keratoconus is a naturally occurring dystrophy of the cornea characterized by progressive deformation (steepening) of the cornea while corneal ectasia is keratoconus that occurs after refractive surgery. Both lead to functional loss of vision and need for corneal transplantation. Corneal collagen cross-linking (CXL) is performed with the photosensitizer riboflavin (vitamin B2) and ultraviolet A (UVA) irradiation. There are 2 protocols for CXL.
      1. Epithelium-off CXL (also known as “epi-off”): In this method, a portion of the central corneal epithelium is removed under topical anesthesia to allow better diffusion of the photosensitizer riboflavin into the stroma.
      2. Epithelium-on CXL (also known as “epi-on” or transepithelial): In this method, the corneal epithelial surface is left intact (or may be partially disrupted) and a longer riboflavin loading time is needed.
      Currently the only CXL treatment approved by the FDA is the epithelium-off method. There are no FDA-approved CXL treatments using the epithelium-on method.
  • A keratoprosthesis is an artificial cornea intended to restore vision in individuals with severe bilateral corneal disease for whom the standard surgical intervention (a corneal transplant, performed via penetrating keratoplaty–PK) is contraindicated. A Keratoprosthesis consists of a central optic held in a cylindrical frame. The device replaces the section of the cornea that has been removed, and, along with being held in place by the surrounding tissue, may be covered by a membrane to further anchor the prosthesis.There are currently two FDA-approved keratoprostheses: the Boston (Dohlman-Doane) keratoprosthesis (Boston KPro), and the AlphaCor ® (Chirila keratoprosthesis). Available outcomes data for the two devices suggest that the Boston KPro is associated with fewer complications.
    • In 2015, the American Academy of Ophthalmology (AAO) published the findings of a systematic review into the safety and efficacy of the Boston KPro. The study’s inclusion criteria were: language of publication, English, and, in the case of retrospective studies, a collective sample size of at least 25 eyes. The search ultimately yielded 22 observational studies but no RCTs. In terms of outcomes, the study found that the proportion of patients with visual acuity of 20/200 after surgery ranged from 54% to 84% in the 10 studies reporting this outcome. Five studies reported that 11% to 39% of treated eyes attained visual acuities of 20/40 or better. In terms of safety and durability outcomes, the review found 14 studies reporting on retention rates (eyes retaining the KPro device without loss, extrusion or dehiscence of the device); retention rates ranged from 65% to 100% (mean, 88%). The most common reasons for KPro loss were corneal melts with device exposure or extrusion, endophthalmitis, infectious keratitis, or corneal ulceration. The most common complication was retroprosthetic membrane formation, which ranged from 1% to 65% (mean, 30%) in the 13 studies reporting complications.
    • A 2011 study by Jeraskova et al. reported on the long-term results of AlphaCor implantations (n = 15). The survival rate of the device at one, two, and three years was 87%, 58%, and 42%, respectively. Postoperative visual acuity ranged from hand movement to 0.8. The most significant complications were stromal melt (n =9), optic deposition (n = 3), and retrospective membrane formation (n = 3). The most common device-unrelated complication was trauma ( n = 3). All complications were managed without eye loss. The authors concluded that Alphacor provides a treatment option for individuals with corneal blindness in whom donor tissue graft would not succeed.

References


Abad JC, Vargas A. Gaping of radial and transverse corneal incisions occurring early after CXL. J Cataract Refract Surg. 2011;37(12):2214-2217.

Ahmad S, Mathews PM, Lindsley K, et al. Boston Type 1 Keratoprosthesis versus repeat donor keratoplasty for corneal graft failure: a systematic review and meta-analysis. Ophthalmology. 2016;123(1):165-177.

American Academy of Ophthalmology Cornea/External Disease Panel. Preferred Practice Pattern® Guidelines. Corneal Ectasia. San Francisco, CA: American Academy of Ophthalmology; 2013. Available at: https://www.aao.org/preferred-practice-pattern/corneal-ectasia-ppp--2013. Accessed January 5, 2018.

American Academy of Ophthalmology. EyeWiki™. Corneal Collagen Cross-Linking. (Revised 11/27/2017). Available at: http://eyewiki.aao.org/Corneal_Collagen_Cross-Linking. Accessed January 5, 2018.

Asri D, Touboul D, Fournie P, et al. Corneal collagen crosslinking in progressive keratoconus: multicenter results from the French National Reference Center for Keratoconus. J Cataract Refract Surg. 2011;37(12):2137-2143.

Avedro Inc. Photorexa® Viscous and Photorexa® Prescribing Label. 07/2016. Available at: http://www.accessdata.fda.gov/drugsatfda_docs/label/2016/203324s000lbl.pdf. Accessed January 5, 2018.

Awdeh RM, Abbey AM, Vroman DT, et al. Phototherapeutic keratectomy for the treatment of subepithelial fibrosis and anterior corneal scarring after descemet stripping automated endothelial keratoplasty. Cornea. 2012;31(7):761-3.

Blackmon S, Semchyshyn T, Kim T, Penetrating and lamellar keratoplasy. In: Tasman W, Jaegar EA. Duane's Ophthalmology. 2006 edition. Ebook: Lippincott Williams & Wilkins. [The link to this reference is no longer active on the Oculist Web site.] Available at: http://www.oculist.net/downaton502/prof/ebook/duanes/pages/v6/v6c026.html#top. Accessed March 14, 2017.

Brooks NO, Greenstein S, Fry K, et al. Patient subjective visual function after corneal collagen crosslinking for keratoconus and corneal ectasia. J Cataract Refract Surg. 2012;38(4):615-619.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 80.7: Refractive keratoplasty. [CMS Web site]. 05/01/97. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=72&ncdver=1&bc=BAABAAAAAAAA&. Accessed January 5, 2018.

Caporossi A, Mazzotta C, Baiocchi S, et al. Long-term results of riboflavin ultraviolet a corneal collagen cross-linking for keratoconus in Italy: the Siena eye cross study. Am J Ophthalmol. 2010;149(4):585-593.

Caporossi A, Mazzotta C, Baiocchi S, et al. Riboflavin-UVA-induced corneal collagen cross-linking in pediatric patients. Cornea. 2012;31(3):227-231.

Center for Drug Evaluation and Research: FDA. Summary Review: Application Number 203324Orig2s000. July 15, 2016. Available at: http://www.accessdata.fda.gov/drugsatfda_docs/nda/2016/203324Orig2s000SumR.pdf. Accessed January 5, 2018.

Chan CC, LoVerde L, Qiang J, et al. Incidence, Risk Factors, and Surgical Management of Boston Type 1 Keratoprothesis Corneal Melts, Leaks, and Extrusions. Cornea. 2016;35(8):1049-1056.

Chunyu T, Xiujun P, Zhengjun F, et al. Corneal collagen cross-linking in keratoconus: a systematic review and meta-analysis. Sci Rep. 2014;4:5652.

Ciolino JB, Belin MW, Todani A, et al. Retention of the Boston keratoprosthesis type 1: multicenter study results. Ophthalmology. Jun 2013;120(6):1195-1200.

Company Benefit Contracts.

Crawford GJ, Hicks CR, Lou X, et al. The Chirila Keratoprosthesis: phase I human clinical trial. Ophthalmology. 2002;109(5):883-889.

Davis LJ, Schechtman KB, Wilson BS, et al. Longitudinal changes in visual acuity in keratoconus. Invest Ophthalmol Vis Sci. 2006;47(2):489-500.

De La Paz MF, De Toledo JA, Charoenrook V, et al. Impact of clinical factors on the long-term functional and anatomic outcomes of osteo-odonto-keratoprosthesis and tibial bone keratoprosthesis. Am J Ophthalmol. 2011;151(5):829-839.

Dunlap K, Chak G, Aquavella JV, et al. Short-term visual outcomes of Boston type 1 keratoprosthesis implantation. Ophthalmology. 2010;117(4):687-692.

Falcinelli G, Falsini B, Taloni M, et al. Modified osteo-odonto-keratoprosthesis for treatment of corneal blindness: long-term anatomical and functional outcomes in 181 cases. Arch Ophthalmol. 2005;123(10):1319-1329.

Gkika M, Labiris G, Kozobolis V. Corneal collagen cross-linking using riboflavin and ultraviolet-A irradiation: a review of clinical and experimental studies. Int Ophthalmol. 2011;31(4):309-319.

Gokhale NS. Corneal endothelial damage after collagen cross-linking treatment. Cornea. 2011;30(12):1495-1498.

Goldman DR, Hubschman JP, Aldave AJ, et al. Postoperative posterior segment complications in eyes treated with the Boston type I keratoprosthesis. Retina. 2013;33(3):532-541.

Hersh PS, Greenstein SA, Fry KL. Corneal collagen crosslinking for keratoconus and corneal ectasia: One year results. J Cataract Refract Surg. 2011;37(1):149-160.

Hicks CR, Crawford GJ, Lou X, et al. Corneal replacement using a synthetic hydrogel cornea, AlphaCor: device, preliminary outcomes and complications. Eye (Lond). 2003;17(3):385-392.

Hoffart L, Carles G, Matonti F. Lamellar corneal lenticule graft to treat keratolysis after AlphaCor keratoprosthesis implantation. Eur J Ophthalmol. 2015;25(1):1-7.

Hughes EH, Mokete B, Ainsworth G, et al. Vitreoretinal complications of osteoodontokeratoprosthesis surgery. Retina. 2008;28(8):1138-1145.

Jiraskova N, Roszival P, Burova M, et al. AlphaCor artificial cornea: clinical outcome. Eye (Lond). 2011;25(9):1138-46.

Ladas JG. Highlights of the American Society of Cataract and Refractive Surgery (ASCRS)/American Society of Ophthalmic Administrators (ASOA) 2004 Symposium and Congress. [Medscape Web site]. 05/20/04. Available at: http://www.medscape.com/viewarticle/477705_print. Accessed January 5, 2018.

Lee WB, Shtein RM, Kaufman SC, et al. Boston Keratoprosthesis: outcomes and complications: a report by the American Academy of Ophthalmology. Ophthalmology. 2015;122(7):1504-1511.

Lee WB, Shtein RM, Kaufman SC, et al. Boston Keratoprosthesis: outcomes and complications: a report by the American Academy of Ophthalmology. Ophthalmology. 2015;122(7):1504-1511.

Liu C, Okera S, Tandon R, et al. Visual rehabilitation in end-stage inflammatory ocular surface disease with the osteo-odonto-keratoprosthesis: results from the UK. Br J Ophthalmol. 2008;92(9):1211-1217.

McAnena L, Doyle F, O'Keefe M. Cross-linking in children with keratoconus: a systematic review and meta-analysis. Acta Ophthalmol. 2017;95(3):229-239.

McMahon TT, Edrington TB, Szczotka-Flynn L, et al. Longitudinal changes in corneal curvature in keratoconus. Cornea. 2006;25(3):296-305.

Medicare Program—Revisions to Hospital Outpatient Prospective Payment System and Calendar Year 2007 Payment Rates; Final Rule. Federal Register. 2006;71(226):68052-68054.

Meiri Z, Keren S, Rosenblatt A, et al. Efficacy of corneal collagen cross-linking for the treatment of keratoconus: a systematic review and meta-analysis. Cornea. 2016;35(3):417-428.

Michael R, Charoenrook V, de la Paz MF, et al. Long-term functional and anatomical results of osteo- and osteoodonto-keratoprosthesis. Graefes Arch Clin Exp Ophthalmol. 2008;246(8):1133-1137.

National Institute for Health and Care Excellence (NICE). Photochemical corneal collagen cross-linkage using riboflavin and ultraviolet A for keratoconus and keratectasia [IPG466]. 2013. Available at: https://www.nice.org.uk/guidance/ipg466. Accessed January 5, 2018.

Odorcic S, Haas W, Gilmore MS, et al. Fungal infections after Boston Type 1 Keratoprosthesis Implantation: literature review and in vitro antifungal activity of hypochlorous acid. Cornea. 2015;34(12):1599-1605.

Padmanabhan P, Rachapalle Reddi S, Rajagopal R, et al. Corneal collagen cross-linking for keratoconus in pediatric patients-long-term results. Cornea. 2017;36(2):138–143.

Papaioannou L, Miligkos M, Papathanassiou M. Corneal Collagen Cross-Linking for Infectious Keratitis: A Systematic Review and Meta-Analysis. Cornea. 2016;35(1):62-71.

Raiskup F, Theuring A, Pillunat LE, et al. Corneal collagen crosslinking with riboflavin and ultraviolet-A light in progressive keratoconus: ten-year results. J Cataract Refract Surg. 2015;41(1):41-46.

Raiskup-Wolf F, Hoyer A, Spoerl E, et al. Collagen crosslinking with riboflavin and ultraviolet-A light in keratoconus: long-term results. J Cataract Refract Surg. 2008;34(5):796-801.

Renesto Ada C, Barros Jde N, Campos M. Impression cytologic analysis after corneal collagen cross linking using riboflavin and ultraviolet-A light in the treatment of keratoconus. Cornea. 2010;29(10):1139-1144.

Rudnisky CJ, Belin MW, Guo R, et al. Visual acuity outcomes of the Boston Keratoprosthesis Type 1: multicenter study results. Am J Ophthalmol. 2016;162:89-98 e81.

Rudnisky CJ, Belin MW, Todani A, et al. Risk factors for the development of retroprosthetic membranes with Boston keratoprosthesis type 1: multicenter study results. Ophthalmology. 2012;119(5):951-955.

Srikumaran D, Munoz B, Aldave AJ, et al. Long-term outcomes of boston type 1 keratoprosthesis implantation: a retrospective multicenter cohort. Ophthalmology. 2014;121(11):2159-2164.

Sykakis E, Karim R, Evans JR, et al. Corneal collagen cross-linking for treating keratoconus. Cochrane Database Syst Rev. 2015;3:CD010621.

Tan A, Tan DT, Tan XW, et al. Osteo-odonto keratoprosthesis: systematic review of surgical outcomes and complication rates. Ocul Surf. 2012;10(1):15-25.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. LASIK eye surgery: FDA-approved lasers for LASIK. [FDA Web site]. Page last updated 09/22/2017. Available at: https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/SurgeryandLifeSupport/LASIK/ucm192109.htm. Accessed January 5, 2018.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. LASIK [FDA Web site]. Page Last Updated: 06/09/2014. Available at: http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/SurgeryandLifeSupport/LASIK/default.htm. Accessed January 5, 2018.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. 510(k) Summary of Safety and Effectiveness for Dohlman Doane Keratoprosthesis (Mackeen Consultants, Ltd., Bethesda, MD). Original FDA clearance. January 21, 1992. Available at: http://www.accessdata.fda.gov/scripts/cdrh/devicesatfda/index.cfm?db=pmn&id=K915062. Accessed January 5, 2018.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. Boston Keratoprosthesis, Type I and Type II. 510(k) summary. [FDA Web site]. 05/10/2013. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf12/K121203.pdf. Accessed January 5, 2018.

US Food and Drug Administration. FDA Briefing Package for Joint Meeting of the Dermatologic and Ophthalmic Drugs Advisory Committee and Ophthalmic Device Panel of the Medical Devices Advisory Committee NDA 203324: Photrexa Viscous and Photrexa (riboflavin ophthalmic solution) and KXL System (UVA light source) Avedro, Inc. 2015. Available at: https://www.pharmamedtechbi.com/~/media/Supporting%20Documents/The%20Pink%20Sheet%20DAILY/2015/February/22015%20DODAC_ODPB101FDA_Backgrounder.pdf. Accessed January 5, 2018.

Wittig-Silva C, Chan E, Islam FM, et al. A randomized, controlled trial of corneal collagen cross-linking in progressive keratoconus: three-year results. Ophthalmology. 2014;121(4):812-821.

Wittig-Silva C, Whiting M, Lamoureux E, et al. A randomized controlled trial of corneal collagen cross linking in progressive keratoconus: preliminary results. J Refract Surg. 2008;24(7):S720-725.

Xu W, Ye P, Yao K, et al. Conductive keratoplasty for the treatment of astigmatism induced by corneal trauma or incision. J Refract Surg. 2010;26(1): 33-42.

Ye PP, Xu W, Xu HS, et al. Conductive keratoplasty: an approach for the correction of residual hyperopia in post-lasik pseudophakia. Int J Ophthalmol. 2012;5(5):630-3.





Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

MEDICALLY NECESSARY


0402T, 65770, 65772, 65775


THE FOLLOWING CODE IS USED TO REPRESENT CONDUCTIVE KERATOPLASTY

66999


THE FOLLOWING SERVICES ARE BENEFIT CONTRACT EXCLUSIONS EXCEPT FOR GROUPS THAT HAVE PURCHASED THESE SERVICES AS A BENEFIT OPTION

65760, 65765, 65767, 65771



Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

Report the most appropriate diagnosis code in support of medically necessary criteria as listed in the policy


HCPCS Level II Code Number(s)

MEDICALLY NECESSARY


C1818 Integrated keratoprosthesis

L8609 Artificial cornea


THE FOLLOWING SERVICES ARE A BENEFIT CONTRACT EXCLUSION EXCEPT FOR GROUPS THAT HAVE PURCHASED THESE SERVICES AS A BENEFIT OPTION

S0800 Laser in situ keratomileusis (LASIK)

S0810 Photorefractive keratectomy (PRK)

S0812 Phototherapeutic keratectomy (PTK)



Revenue Code Number(s)

0276 Medical/Surgical Supplies and Devices-Intraocular Lens

Coding and Billing Requirements


Cross References


Policy History

Revisions from 11.05.01e:

03/28/2018

This policy has undergone a routine review, and no revisions have been made.

Effective 10/05/2017 this policy has been updated to the new policy template format.

Version Effective Date: 08/02/2017
Version Issued Date: 08/02/2017
Version Reissued Date: 03/28/2018

Connect with Us        


© 2017 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.