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HealthPartners

Coverage criteria policies

Eye Surgery - Refractive

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Refractive eye surgery procedures, other than radial keratotomy, require prior authorization

Radial keratotomy (RK) is not covered as it is not considered medically necessary. Prior authorization is not applicable.

Intraocular lens (IOL) implant after cataract surgery does not require prior authorization

Coverage

As stated in your member contract, refractive eye surgery is not covered when used in otherwise healthy eyes to replace eyeglasses or contact lenses. It may be covered to treat particular corneal diseases per the indications listed below and per your plan documents.

Indications that are covered

  1. Phototherapeutic keratectomy (PTK) is a covered service when used for the treatment of the following:
    1. Corneal scars
    2. Degeneration and dystrophies involving the superficial layer of the cornea
    3. Anterior basement membrane dystrophy, also known as epithelial basement membrane dystrophy (EBMD) resulting in decreased vision and/or recurrent corneal erosions
    4. Recurrent epithelial erosion when standard therapeutic regimens (i.e. lubrication ointment, stromal puncture and scraping the epithelium) have not resolved the problem
  2. Laser-in-situ keratomileusis (LASIK) and photorefractive keratectomy (PRK) are covered services only when used for the treatment of the following:
    1. Anisometropia: ONLY when the condition follows conventional cataract surgery, anterior segment glaucoma surgery, or corneal transplant which has resulted in a significant diopter difference of three (3) making eyeglasses ineffective AND the member is contact lens intolerant.
    2. Astigmatism: ONLY when the condition follows conventional cataract surgery, anterior segment glaucoma surgery or corneal transplant, which has resulted in a diopter difference of two (2) that is not treatable by eyeglasses AND the member is contact lens intolerant.
  3. Intrastromal Corneal Ring Segments (ICRS or INTACS) are covered services only when used for the treatment of keratoconus when ALL of the following criteria are met:
    1. The patient is 21 years of age or older; AND
    2. There is documentation of progressive deterioration in vision, such that the patient can no longer achieve adequate functional vision with contact lenses or spectacles; AND
    3. Corneal transplantation is the only alternative to improve their functional vision; AND
    4. There is documentation that the patient has a clear cornea with a corneal thickness of 450 microns or greater at the proposed incision site.
  4. Standard, non-accommodating intraocular lenses (IOL) are covered as part of routine cataract surgery or as a secondary implant in a patient with aphakia.

Indications that are not covered

  1. Laser-in-situ keratomileusis (LASIK) and photorefractive keratectomy (PRK) are not considered medically necessary for any indication other than those described above.
  2. Implantable lenses or intrastromal corneal ring segments (ICRS or INTACS) are not considered medically necessary for treatment of any indication other than keratoconus as described above.
  3. Accommodating intraocular lenses (AIOL) that are multifocal or correct farsightedness are not considered medically necessary. Examples of non-covered AIOL’s include but are not limited to Crystalens, Toric Lens, and ARrayMultifocal AIOL.

Definitions

Accommodating or multifocal intraocular lenses (AIOL) are enhanced IOL’s which provide near, intermediate and distance vision without spectacles and may also correct astigmatism

Anismetropia is the condition in which the two eyes have different refractive power, so there is unequal focus between the two eyes. Each eye can be nearsighted, farsighted, or a combination of both

Aphakia is the absence of the lens of the eye, due to surgical removal, a perforating wound or ulcer, or congenital anomaly

Astigmatism is an imperfection in the curvature of the cornea — the clear, round dome covering the eye's iris and pupil — or in the shape of the eye's lens

Intraocular lenses (IOL) are single vision medical devices that are routinely implanted inside the eye to replace the eye's natural lens when it is removed during cataract surgery.

Intrastromal Corneal Ring Segments (also known as IICRS, corneal insert, or KeraVision INTACS) are implanted transparent corneal crescents used for the treatment of keratoconus or to correct mild myopia in otherwise healthy eyes to replace wearing eyeglasses or contact lenses.

Keratoconus is a slow, progressive eye disease in which the normally round, dome shaped cornea (the clear outer front portion of the eye) thins and begins to bulge into a cone-like shape. This cone shape is irregular, bending light as it enters the eye and thus distorting vision

Phototherapeutic keratectomy (PTK), Laser-in-situ keratomileusis (LASIK), and photorefractive keratectomy (PRK) are eye surgeries to correct certain refractive disorders, such as myopia, in which a surface layer of the cornea is reshaped with a laser

Presbyopia is a condition where the eye exhibits a progressively diminished ability to focus on the near objects with age

Radial keratotomy (RK) is a corneal incision procedure to correct mild or moderate nearsightedness (myopia) in otherwise healthy eyes to replace wearing eyeglasses or contact lenses.

Refractive eye surgery is any eye surgery used to improve the refractive state of the eye and decrease or eliminate dependency on glasses or contact lenses. This can include various methods of surgical remodeling of the cornea or cataract surgery. A refractive error exists when the light is not bending properly when it passes through the cornea and retina of the eye, thus causing deficiencies in vision.

If available, codes for a procedure, device or diagnosis are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all inclusive.

Codes

Description

65710

Anterior lamellar keratoplasty

65760

Keraomileusis

65771

Radial keratotomy

65785

Implantation of intrastromal corneal ring segments

S0800

Laser in situ keratomileusis (LASIK)

S0810

Photorefractive keratectomy (PRK)

S0812

Phototherapeutic keratectomy (PTK)

The following AIOL’s are not covered:

Codes

Description

S0596

Phakic intraocular lens for correction of refractive error

V2787

Astigmatism correcting function of intraocular lens

V2788

Presbyopia correcting function of intraocular lens

The following IOLs are covered:

Codes

Description

C1780

Lens, intraocular (new technology)

Q1004

New technology intraocular lens category 4 as defined in Federal Register notice

Q1005

New technology intraocular lens category 5 as defined in Federal Register notice

V2630

Anterior chamber intraocular lens

V2631

Iris supported intraocular lens

V2632

Posterior chamber intraocular lens

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. Bower, K. Laser Refractive Surgery. In: UpToDate, Trobe, J. (Ed), UpToDate, Waltham, MA. (Accessed Feb 28, 2017)
  2. Centers for Medicare & Medicaid Services (1997). National Coverage Determination (NCD) for Refractive Keratoplasty (80.7).
  3. Garg, S., McColgin, A., Steinart, R. Phototherapeutic Keratectomy. American Academy of Opthalmology. www.aao.org Published 11.12.13 (Accessed 9.12.16).
  4. Hayes, Inc. Directory. Intacs for the Treatment of Keratoconus. Lansdale, PA: Hayes, Inc. Published Dec, 2012. Updated Dec, 2016.
  5. Hayes, Inc. Directory. Laser In Situ Keratomileusis. Lansdale, PA: Hayes, inc. Published Sept, 2002. Archived
  6. U.S. Food and Drug Administration. INTACS Prescription Inserts for Keratoconus-H040002. Humanitarian Device Exemption (HDE) program. Sunnyvale, CA: FDA 2004
  7. Yanoff, M. & Duker, J. (2014) Corneal Surgery. Opthalmology, Fourth Edition. 4.27;299-307.e1

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Policy activity

  • 01/01/2000 - Date of origin
  • 02/01/2017 - Effective date
Review date
  • 02/2017
Revision date
  • 09/13/2016

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