Corneal Pachymetry is the measurement of corneal thickness and commonly uses either ultrasonic or optical methods. Measurement of corneal thickness in individuals presenting with increased intraocular pressure assists in determining if there is a risk of glaucoma or if the individual’s increased eye pressure is the result of abnormal corneal thickness. The test must be integral to the medical management decision-making of the patient. Coverage is limited to ophthalmologists and optometrists.

Corneal pachymetry is considered to be medically necessary when performed to determine the amount of endothelial trauma sustained during surgery, assessment of the health of the cornea pre-operatively in Fuch’s dystrophy, post ocular trauma and for the assessment of corneal thickness or (in suspected glaucoma) following the diagnosis of increased intraocular pressure prior to the initiation of a treatment regimen for glaucoma. It is expected that a service for a corneal thickness measurement following the diagnosis of increased intraocular pressure will be performed once in a lifetime per provider, unless there has been interval corneal trauma or surgery. The lifetime limit ONLY applies for the glaucoma measurement and not for the other indications listed for this service.

Corneal pachymetriy is considered to be medically necessary when performed only by ophthalmologists and optometrists.

Corneal pachymetry will not be reimbursed and will be denied as not medically necessary when used in preparation for surgery to reshape the cornea of the eye for the purpose of correcting visual problems (refractive surgery), such as myopia (nearsightedness) and hyperopia (farsightedness). When the change in the corneal shape results from a previous partial or complete corneal transplant, pachymetry is covered.

Whether patients have been previously diagnosed and are under treatment for glaucoma or are newly diagnosed, pachymetry will be covered once per lifetime per provider, or more frequently in cases where there has been surgical or non-surgical trauma.

Services performed for conditions other than those listed on this policy and services exceeding the frequency guideline will be considered not medically necessary. A provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

Documentation Requirements

Medical record documentation maintained by the ordering/referring physician must indicate the medical necessity for performing the test and the test results. In addition, if the service exceeds the frequency parameter listed in this policy, documentation of medical necessity must be submitted. This information is usually found in the history and physical, office/progress notes, or test results.

If the provider of the service is other than the ordering/referring physician, that provider must maintain hard copy documentation of test results and interpretation, along with copies of the ordering/referring physician’s order for the studies. The physician must state the clinical indication/medical necessity for the study in her order for the test.

Documentation should contain a history and physical which supports the diagnosis for which this service is being rendered.

Utilization Guidelines
These services are expected to be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.

It is also expected that services for the measurement of corneal thickness following the diagnosis of increased intraocular pressure will be performed once in a lifetime, unless there has been interval corneal trauma, surgery or other corneal indications such as keratoconus, bullous kerapathy or other corneal dystrophies.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

CMS Manual System, Pub 100-2, Medicare Benefit Policy, Chapter 15, Section 280.1

CMS Manual System, Pub 100-2, Medicare Benefit Policy, Chapter 16, Section 90

Use of these codes does not guarantee reimbursement. The patient’s medical record must document that the coverage criteria in this policy have been met.