Mountain State Medical Policy Bulletin |
Section: | Surgery |
Number: | S-41 |
Topic: | Corneal Surgery to Correct Refractive Errors and Phototherapeutic Keratectomy |
Effective Date: | May 25, 2009 |
Issued Date: | May 25, 2009 |
Date Last Reviewed: | 04/2009 |
Indications and Limitations of Coverage
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:
Correction of such refractive problems by any of these corneal surgical procedures is ineligible for payment. A participating, preferred, or network provider can bill the member for the denied service. 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 65710-65756. 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:
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 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 should be maintained in the provider's records. However, based on medical record documentation, diagnosis other than those listed above may be given individual consideration for medical necessity. It will be necessary for the provider to submit medical records and/or additional documentation to determine coverage in this situation. 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. Insertion of intrastromal corneal ring segments (e.g., INTACS) is 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 (371.60-371.62) who meet ALL of the following criteria:
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. |
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65710 | 65730 | 65750 | 65755 | 65756 | 65760 |
65765 | 65767 | 65771 | 65772 | 65775 | 76510 |
76511 | 76512 | 76513 | 76514 | 76516 | 76519 |
S0800 | S0810 | S0812 | 0099T |
This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits or a contract. Benefits are determined by the Federal Employee Program. |
National Blue Cross Blue Shield Association Medical Policy 9.03.07, Phototherapeutic Keratectomy (PTK), 01/2008 Modified Intracorneal Ring Segment Implantation (INTACS) for the Management of Moderate to Advanced Keratoconus - Efficacy and Complications, Cornea, Volume 25, No. 1, 01/2006 Kymionis GD, Siganos CS, Tsiklis NS, Anastasakis A, Yoo SH, Pallikaris AI, et al. Long-term follow-up of Intacs in Keratoconus, American Journal of Ophthalmology. 2007;143(2):236-244 Rabinowitz YS, Intacs for keratoconus, Current Opinion in Ophthalmology. 2007;18(4):279-283 Colin J, Malet FJ, Intacs for the correction of keratoconus: Two-year follow-up, Journal of Cataract & Refractive Surgery. 2007;33(1):69-74 Samimi S, Leger F, Touboul D, Colin J, Histopathological findings after intracorneal ring segment implantation in keratoconic human corneas, Journal of Cataract & Refractive Surgery. 2007;33(2):247-253 |
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