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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.

Corneal collagen crosslinking requires 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. IOL implant for any other indication requires 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
    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
    3. Corneal transplantation is the only alternative to improve their functional vision
    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. Conventional, epithelium-off, corneal collagen crosslinking (C-CXL) is covered for the treatment of progressive keratoconus or corneal ectasia following refractive surgery when all of the following criteria are met:
    1. The procedure is completed using an FDA-approved drug/device system
    2. The member is 14-65 years of age
    3. Documentation indicates progressive deterioration in vision which has not responded to standard conservative treatments (e.g. spectacles, contact lenses, ICRS or INTACS).
  5. 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. Conventional epithelium-off corneal collagen crosslinking is considered investigational for any other indication other than those described above.
  4. All other corneal crosslinking procedures other than conventional (e.g. epithelium-on, trans-epithelial, or CXL –plus) are considered investigational.
  5. Accommodating intraocular lenses (AIOL) that are multifocal or correct farsightedness are not considered medically necessary. .
  6. Intraocular lens replacement surgery (also known as refractive lens exchange or clear lens extraction) for correction of myopia, hyperopia or presbyopia is not considered medically necessary. Intraocular lens implant is considered medically necessary only for the indications noted in criterion # 4 above.

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

Corneal collagen cross-linking is a procedure that is intended to increase the biomechanical strength of collagen fibrils of the cornea in order to avoid the progression of keratoconus and subsequently the need for corneal transplantation. The minimally invasive procedure involves applying liquid riboflavin eye drops to the surface of the eye, followed by a controlled application of ultraviolet light. This is believed to strengthen and increase the biomechanical stiffness of the corneal tissue, thereby flattening the steepened cornea into a more normal shape so that vision improves.

Corneal ectasia is a noninflammatory condition with the defining characteristics of progressive corneal steepening and thinning. Corneal ectasias are associated with decreased uncorrected visual acuity (UCVA), an increase in ocular aberrations, and often a loss of best-corrected distance visual acuity (BCVA).

Hyperopia is farsightedness

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.

Intraocular lens replacement surgery (also known as refractive lens exchange or clear lens extraction) is the removal of a non-cataractous natural lens of the eye with or without intraocular lens placement as a refractive procedure.

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

Myopia is nearsightedness

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 describes the loss of near vision that normally occurs with aging.

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)

0402T

Collagen cross-linking of cornea (including removal of the corneal epithelium and intraoperative pachymetry when performed)

The following codes are considered not medically necessary:

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 only when associated with cataract surgery:

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. American Academy of Ophthalmology/Cornea/External Disease Panel. Preferred Practice Pattern Guidelines. Corneal Ectasia. San Francisco, CA: American Academy of Ophthalmology; 2018. Available at: https://www.aao.org/guidelines-browse?filter=preferredpracticepatternsguideline.
  2. Bower, K. Laser Refractive Surgery. In: UpToDate, Trobe, J. (Ed), UpToDate, Waltham, MA. (Updated Aug 23, 2018).
  3. ECRI Institute. (2018). Corneal Collagen Cross-linking for Treating Corneal Ectasia and Keratoconus. Plymouth Meeting, PA: ECRI Institute.
  4. Garg, S., McColgin, A., Steinart, R. Phototherapeutic Keratectomy. American Academy of Ophthalmology. www.aao.org Published 11.12.13 (Accessed 9.12.16).
  5. Hayes, Inc. Hayes Clinical Research Response. Intraocular Lenses for Astigmatism/Presbyopia. Lansdale, PA: Hayes, Inc.; Dec, 2017.
  6. Hayes, Inc. Hayes Clinical Research Response. TECNIS Toric Lenses for Astigmatism/Presbyopia. Lansdale, PA: Hayes, Inc.; Dec, 2017.
  7. Hayes, Inc. Hayes Clinical Research Response. Monofocal Intraocular Lenses. Lansdale, PA: Hayes, Inc.; Dec, 2017.
  8. Hayes, Inc. Hayes Clinical Research Response. Multifocal Intraocular Lenses. Lansdale, PA: Hayes, Inc.; Dec, 2017.
  9. Hayes, Inc. Hayes Medical Technology Directory Report. Comparative Effectiveness Review: Corneal Collagen Cross-Linking for Treatment of Keratoconus. Lansdale, PA: Hayes, Inc.; Feb, 2018.
  10. Hayes, Inc. Hayes Medical Technology Directory Report. Conventional Corneal Collagen Cross-Linking for Treatment of LASIK-Related Ectasia. Lansdale, PA: Hayes, Inc.; December, 2018.
  11. Hayes, Inc. Hayes Medical Technology Directory Report. Intacs for the Treatment of Keratoconus. Lansdale, PA: Hayes, Inc. March, 2018. .
  12. Hayes, Inc. Directory. Laser In Situ Keratomileusis. Lansdale, PA: Hayes, inc. Published Sept, 2002. Archived
  13. National Institute for Health and Care Excellence. Laser correction of refractive error following non-refractive ophthalmic surgery. (2011). Retrieved from https://www.nice.org.uk/guidance/ipg385
  14. Hersh, P. S., Stulting, R. D., Muller, D., Durrie, D. S., Rajpal, R. K., Binder, P. S., ... & Price Jr, F. (2017). United States multicenter clinical trial of corneal collagen crosslinking for keratoconus treatment. Ophthalmology, 124(9), 1259-1270
  15. Hersh, P. S., Stulting, R. D., Muller, D., Durrie, D. S., Rajpal, R. K., Binder, P. S., ... & Price Jr, F. (2017). US multicenter clinical trial of corneal collagen crosslinking for treatment of corneal ectasia after refractive surgery. Ophthalmology, 124(10), 1475-1484.
  16. Jacobs, D. Corneal abrasions and corneal foreign bodies: Management. In: UpToDate, Trobe, J. and Bachur, R. UpToDate, Waltham, MA. (Accessed on Jan 21, 2019)
  17. O'Brart, D. P., Patel, P., Lascaratos, G., Wagh, V. K., Tam, C., Lee, J., & O'Brart, N. A. (2015). Corneal cross-linking to halt the progression of keratoconus and corneal ectasia: seven-year follow-up. American journal of ophthalmology, 160(6), 1154-1163.
  18. U.S. Food and Drug Administration. INTACS Prescription Inserts for Keratoconus-H040002. Humanitarian Device Exemption (HDE) program. Sunnyvale, CA: FDA 2004
  19. Wayman, L. Keratoconus. In: UpToDate, Trobe, J. (Ed), UpToDate, Waltham, MA. (Accessed on Nov 5, 2018).
  20. Yanoff, M. & Duker, J. (2014) Corneal Surgery. Ophthalmology, Fourth Edition. 4.27;299-307.e1

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Policy activity

  • 01/01/2000 - Date of origin
  • 03/01/2019 - Effective date
Review date
  • 02/2019
Revision date
  • 01/23/2019

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