Corneal Collagen Cross-Linking

Section: Surgery
Effective Date: March 01, 2020
Revised Date: January 22, 2020
Last Reviewed: January 22, 2020

Description

Corneal collagen cross-linking (CXL) is a photochemical procedure 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 the need for corneal transplantation.

Collagen crosslinks are biochemical markers which provide a measurement of bone resorption.

Criteria

CXL using riboflavin and ultraviolet A may be considered medically necessary in individuals who have failed conservative treatment (e.g., spectacle correction, rigid contact lens) when used for EITHER of the following conditions;

  • Progressive keratoconus; or
  • Corneal ectasia after refractive surgery

CXL using riboflavin and ultraviolet A is considered experimental/investigational and therefore non-covered for all other indications because of insufficient supporting evidence in peer-reviewed literature.

Procedure Codes

0402T

Collagen crosslinks, any method

Collagen crosslinks, any method, is considered not medically necessary.

Procedure Codes

82523

Diagnosis Codes

Covered diagnosis codes for procedure code 0402T

H18.601 H18.602 H18.603 H18.611 H18.612 H18.613 H18.621
H18.622 H18.623 H18.711 H18.712 H18.713

 

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-22-2020 Annual Review

Links

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving and the Company reserves the right to review and update medical policy periodically.