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 (65771)
• photorefractive keratectomy (PRK) - S0810
• laser-assisted in-situ keratomileusis (LASIK) - S0800
• corneal ring implant (0099T), and
• lamellar refractive keratoplasty (keratomileusis - 65760, keratophakia - 65765, epikeratoplasty - 65767)

Correction of such refractive problems by any of these corneal surgical procedures is ineligible for payment. However, the correction of astigmatism resulting from trauma or from previous eligible surgery (e.g., cataract surgery) is eligible for payment under codes 65772-65775. The astigmatism in this case is considered a complication of the first surgery. Corneal surgery performed to correct aphakia is also eligible for payment. Claims reporting such surgery should be reported under unlisted procedure code 66999 and be medically reviewed.

These procedures should not be confused with corneal transplants (also called keratoplasties) which are eligible services under codes 65710-65755. Refer to Medical Policy Bulletin S-116 for information on corneal transplants and penetrating keratoplasty.

Phototherapeutic Keratectomy (PTK)

Another procedure, phototherapeutic keratectomy (PTK - S0812), must also be distinguished from corneal refractive surgeries (e.g., photorefractive keratectomy or PRK - S0810). Phototherapeutic keratectomy 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. Phototherapeutic keratectomy is considered eligible for the following conditions:

• Corneal scar and opacities (371.00-371.05)
• Stromal corneal dystrophy (371.56)

If phototherapeutic keratectomy is reported for a condition/diagnosis other than those listed above, it is considered not medically necessary. Therefore, they are not covered. A participating, preferred, or network provider cannot bill the member for the denied service. However, based on medical record documentation, diagnosis other than those listed above may be given individual consideration for medical necessity.

Implantation of Intrastromal Corneal Ring Segments (0099T)

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.

Implantation of intrastromal corneal ring segments (e.g., INTACS) is considered experimental/investigational for the treatment of keratoconus (371.60-371.62) and therefore, not covered and not eligible for payment.  There are inadequate data to permit scientific conclusions regarding implantation of intrastromal corneal ring segments as a treatment of keratoconus, and long-term outcomes need to be evaluated.  A participating, preferred, or network provider can bill the member for the denied service.

Date Last Reviewed: 02/2007

Additionally, any pre- and post-operative evaluations and measurements [e.g., ophthalmic echography (76510-76519), keratometry, pachymetry (76514), etc.] performed in conjunction with the ineligible procedures should be denied.

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.

National Blue Cross Blue Shield Association Medical Policy 9.03.07, Phototherapeutic Keratectomy (PTK), 12/2006

Modified Intracorneal Ring Segment Implantation (INTACS) for the Management of Moderate to Advanced Keratoconus - Efficacy and Complications, Cornea, Volume 25, No. 1, 01/2006