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Corneal Surgery to Correct Refractive Errors and Phototherapeutic Keratectomy

Section: Surgery
Effective Date: July 01, 2018
Revised Date: November 22, 2019

Description

Corneal surgery is performed to change the shape of the cornea which will correct vision problems such as myopia (nearsightedness), hyperopia (farsightedness), and astigmatism. Corneal surgeries performed for this purpose include radial keratotomy, photorefractive keratectomy (PRK), laser-assisted in-situ keratomileusis (LASIK), keratomileusis, keratophakia, and epikeratoplasty.

Phototherapeutic keratectomy (PTK) involves the use of the excimer laser to treat visual impairment or irritative symptoms relating to diseases of the anterior cornea. PTK functions by removing anterior stromal opacities or eliminating elevated cornea lesions while maintaining a smooth corneal surface.

Intrastromal corneal ring segments (e.g., INTACS) consist of micro-thin methylmethacrylate inserts of variable thickness that are implanted on the perimeter of the cornea. They are used in refractive surgery to correct mild myopia (see above), and as a treatment of keratoconus. The inserts help restore vision in keratoconus patients by flattening and repositioning the cornea.

Criteria

Corneal refractive surgery may be considered medically necessary when ANY ONE of the following is met:

  • Correction of astigmatism resulting from trauma or from a previous eligible surgery (e.g., cataract surgery); or
  • Correction of aphakia.

Cornealrefractive surgeries for all other indications are considerednon-covered.

NOTE: These procedures should not be confused with corneal transplants (also called keratoplasties).

Procedure Codes

65760

65765

65767

65771

65772

65775

66999

S0800

S0810

Phototherapeutic Keratectomy (PTK)

PTK may be considered medically necessary for ANYONE of the following conditions:

  • Corneal scar and opacities (including post-traumatic, post-infectious, post-surgical, and secondary to pathology); or
  • Superficial corneal dystrophy (including granular, lattice and Reis-Bückler’s dystrophy); or
  • Epithelial membrane dystrophy; or
  • Irregular corneal surfaces due to Salzmann’s nodular degeneration or keratoconus nodule; or
  • Recurrent corneal erosions when more conservative measures (e.g., lubricants, hypertonic saline, patching, bandage contact lenses, gentle debridement of severely aberrant epithelium) have failed to halt the erosions.

NOTE: PTK should not be confused with photorefractive keratectomy (PRK). Although technically the same procedure, PTK is used for the correction of particular corneal diseases whereas PRK involves the use of the excimer laser for correction of refractive errors (e.g., myopia, hyperopia, astigmatism, and presbyopia) in persons with otherwise non-diseased corneas.

For all other indications, PTK is considered not medically necessary.

Procedure Codes

S0812

Intrastromal Corneal Ring Segments

Insertion of intrastromal corneal ring segments (e.g., INTACS) may be considered medically necessary when provided in accordance with the Humanitarian Device Exemption (HDE) specifications of the U.S. Food and Drug Administration (FDA) for the treatment of patients with keratoconus who meet ALL of the following criteria:

  • Who have experienced a progressive deterioration in their vision, such that they can no longer achieve adequate functional vision on a daily basis with their contact lenses or spectacles; and
  • Who are 21 years of age or older; and
  • Who have clear central corneas; and
  • Who have a corneal thickness of 450 microns or greater at the proposed incision site; and
  • Who have corneal transplantation as the only option remaining to improve their functional vision.

For all other indications, implantation of intrastromal corneal ring segments is considered not medically necessary.

Any pre- and post-operative evaluations and measurements [e.g., ophthalmic echography, keratometry, pachymetry, etc.] performed in conjunction withservices identifiedwith ineligible proceduresare non-covered.

Procedure Codes

65785

76510

76511

76512

76513

76514

76516

76519

Contact Lenses for Keratoconus

When a covered individual or group customer benefit, contact lenses are covered for the treatment of keratoconus.

Diagnosis Codes

Covered Diagnosis Codes for Procedure Code S0812

A18.59

E50.6

H17.9

H17.00

H17.01

H17.02

H17.03

H17.10

H17.11

H17.12

H17.13

H17.89

H17.811

H17.812

H17.813

H17.819

H17.821

H17.822

H17.823

H17.829

H18.9

H18.50

H18.51

H18.52

H18.53

H18.54

H18.55

H18.59

H18.451

H18.452

H18.453

H18.459

H18.601

H18.602

H18.603

H18.609

H18.611

H18.612

H18.613

H18.619

H18.621

H18.622

H18.623

H18.629

H18.831

H18.832

H18.833

H18.839

H18.891

H18.892

H18.893

H18.899

Q13.3

Covered Diagnosis Codes for Procedure Code 65785

H18.601

H18.602

H18.603

H18.609

H18.611

H18.612

H18.613

H18.619

H18.621

H18.622

H18.623

H18.629

Covered Diagnosis Codes for Procedure Code 65772, 65775, 66999

H18.10

H18.11

H18.12

H18.13

H27.00

H27.01

H27.02

H27.03

Q12.3

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