Our Member Services Representatives are unavailable Friday, April 10, due to the holiday.

 

CORONAVIRUS (COVID-19)

Resources on COVID-19 and how BCBSND is responding to help protect all North Dakotans

Corneal Collagen Cross-Linking

Section: Surgery
Effective Date: January 01, 2019
Last Reviewed: January 14, 2019

Description

Corneal collagen cross-linking (CXL) is a photochemical procedure approved by the Food and Drug Administration for the treatment of progressive keratoconus and corneal ectasia. Keratoconus is a 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.

Criteria

Coverage is subject to the specific terms of the member's benefit plan

Corneal collagen cross-linking using riboflavin and ultraviolet A may be considered medically necessary as a treatment of progressive keratoconus or corneal ectasia after refractive surgery in patients who have failed conservative treatment (eg spectacle correction, rigid contact lens). 

Corneal collagen cross-linking using riboflavin and ultraviolet A is considered investigational for all other indications. 

Policy Guidelines

Progressive keratoconus or corneal ectasia is defined as 1 or more of the following: 

  • An increase of 1 D in the steepest keratometry value 
  • An increase of 1 D in regular astigmatism evaluated by subjective manifest refraction 
  • A myopic shift (decrease in the spherical equivalent) of 0.50 D on subjective manifest refraction 
  • A decrease ≥0.1 mm in the back optical zone radius in rigid contact lens wearers where other information was not available. 

Procedure Codes

0402T   J2787

Diagnosis Codes

H18.601  H18.602  H18.603  H18.611  H18.612  H18.613 
H18.621  H18.622  H18.623  H 18.711  H18.712  H18.713

Links