CurrentAetnaPolicy 0681

Corneal Pachymetry

Defines Aetna's medical necessity, experimental/investigational determinations, limitations, and related coding for ultrasound corneal pachymetry (measurement of corneal thickness). Only the ultrasound method is considered.

Policy Summary

PayerAetna

PolicyCorneal Pachymetry

Policy CodePolicy 0681

Change TypeNo material change

Effective DateJan 2, 2004

Next Review DateJul 25, 2024

Key ActionDocument one of the covered indications in the medical record to support medical necessity for ultrasound corneal pachymetry and verify plan-level exclusions for refractive surgery where applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

11Covered Indications Listed

9Experimental/Investigational Indications

1Covered CPT Code

1Lifetime testing limit for glaucoma

Coverage Summary

Ultrasound corneal pachymetry is a non-invasive ultrasonic technique that measures corneal thickness by placing an ultrasonic probe on the anesthetized central cornea; measurements typically take less than 30 seconds per eye. The procedure is used primarily in evaluating corneal disease and in assessing persons at risk for glaucoma.

Evidence from the Ocular Hypertension Treatment Study (OHTS) identified central corneal thickness less than 556 microns as a statistically significant predictor of development of glaucoma in persons with ocular hypertension (IOP ≥24 mm Hg). However, OHTS measured corneal thickness after study initiation and did not use pachymetry to guide therapy, and its conclusions are limited to persons with ocular hypertension — the value of pachymetry for screening or guiding therapy in populations without ocular hypertension is not established.

Corneal Pachymetry - Key Scope and Thresholds

scope_summaryDefines Aetna's medical necessity, experimental/investigational determinations, limitations, and related coding for ultrasound corneal pachymetry (measurement of corneal thickness). Only the ultrasound method is considered.

Frequency for repeat testing for corneal diseases/injuriesNo more frequently than once every 6 months

Glaucoma indication testing frequencyOnce per lifetime

policy_statusCURRENT

policy_number0681

Medical Necessity

Aetna considers ultrasound corneal pachymetry medically necessary for any ONE of the following indications:

ANY of the following

Anatomical narrow angles
Bullous keratopathy
Corneal edema
Corneal refractive surgery (pre- and post-operative evaluation)
Coverage may be excluded under benefit plans that exclude refractive surgery; check plan documents
Corneal transplant (penetrating keratoplasty) (pre- and post-operative evaluation)
Evaluation of complications of corneal refractive surgery (once)
Evaluation of corneal rejection post penetrating keratoplasty
Fuchs' endothelial dystrophy
Persons who recently had laser iridotomy for the treatment of narrow angle glaucoma (acute/closed-angle glaucoma)
Persons with glaucoma or glaucoma suspects (testing is considered medically necessary once per lifetime)Once per lifetime
Testing is considered medically necessary once per lifetime
Posterior polymorphous dystrophy

No more frequently than once every 6 months

Repeat ultrasound corneal pachymetry for corneal diseases and injuries (indications D through I) is not medically necessary if performed more frequently than once every 6 months

Experimental / Investigational (Not Medically Necessary)

Experimental and Investigational (Not Medically Necessary)

Aetna considers corneal pachymetry experimental and investigational for the following indications because effectiveness has not been established:

ANY of the following

Screening test for glaucoma for persons without signs or symptoms of glaucoma or elevated intra-ocular pressure
Diagnosis of Marfan syndrome
Diagnosis or monitoring of Terrien's corneal marginal degeneration
Evaluation of granular corneal dystrophy/stromal dystrophy
Evaluation of keratoconus
Evaluation of nodular episcleritis
Management of pterygium (e.g., evaluating risk of increased intra-ocular pressure following pterygium surgery)
Management of pseudo-exfoliation syndrome
Monitoring of persons on hydroxychloroquine (Plaquenil)

Policy note: Corneal pachymetry is of no proven value in the work-up of persons prior to cataract surgery unless corneal disease is documented.

See CPB 0508 - Cataract Surgery

Plan-specific exclusions and notes:

Most Aetna benefit plans exclude coverage of refractive surgery; corneal pachymetry for evaluation of persons undergoing corneal refractive surgery is excluded from coverage under plans with these provisions. Verify member benefit plan descriptions.

Corneal pachymetry is of no proven value in the work-up prior to cataract surgery unless corneal disease is documented; check plan documents for coverage determinations.

Coding

Covered CPTCPTCovered

76514

Ophthalmic ultrasound, diagnostic; corneal pachymetry, unilateral or bilateral (determination of corneal thickness)

CPT Codes Not Covered for Indications ListedCPTNot Covered

66830-66984

Removal of cataract (range listed as not covered for indications in CPB)

Other Related CPTCPT

65710-65775	Keratoplasty
65820	Goniotomy
66761	Iridotomy/iridectomy by laser surgery (eg, for glaucoma) (per session)
92020	Gonioscopy (separate procedure)
92100-92130	Serial tonometry and tonography

Related HCPCSHCPCS

G0117	Glaucoma screening for high risk patients furnished by an optometrist or ophthalmologist
G0118	Glaucoma screening for high risk patients furnished under the direct supervision of an optometrist or ophthalmologist
S0800	LASIK
S0810	Photorefractive keratectomy (PRK)
S0812	Phototherapeutic keratectomy (PTK)

ICD-10 Codes Covered if Selection Criteria MetICD-10Covered

H18.10-H18.239	Corneal edema and bullous keratopathy
H18.51	Endothelial corneal dystrophy [Fuchs' only]
H18.59	Other hereditary corneal dystrophies [posterior polymorphous corneal dystrophy]
H40.001-H40.1394	Glaucoma (range as listed)
H40.151-H40.33x4	Glaucoma (additional ranges listed)
H40.50x0-H42	Glaucoma (additional ranges listed)
H40.40x0-H40.43x4	Glaucoma secondary to eye inflammation
H47.231-H47.239	Glaucomatous optic atrophy [cupping]
Q15.0	Congenital glaucoma [Buphthalmos]
T86.840	Corneal transplant rejection

1–10 of 11

1/2

ICD-10 Codes Not Covered / Experimental Indications (not all-inclusive)ICD-10Not Covered

B50.0-B54	Malaria
H11.001-H11.069	Pterygium of eye
H15.121-H15.129	Nodular episcleritis
H18.461-H18.469	Peripheral corneal degeneration [Terrien's corneal marginal degeneration]
H18.531-H18.539	Granular corneal dystrophy
H18.601-H18.629	Keratoconus
H25.011-H26.9 H28	Age-related and other cataract (ranges listed)
H40.1410-H40.1494	Capsular glaucoma with pseudoexfoliation of lens
M05.40-M06.9	Rheumatoid arthritis [not covered for monitoring plaquenil]
M32.0-M32.0	Systemic lupus erythematosus (SLE) [not covered for monitoring plaquenil]

1–10 of 14

1/2

Provider Actions

Documentation Required

Indication documentation required

Document one of the covered indications in the medical record to support medical necessity for ultrasound corneal pachymetry and verify plan-level exclusions for refractive surgery where applicable.

Affected code: 76514
Most Aetna benefit plans exclude refractive surgery — corneal pachymetry for refractive surgery is excluded under those plans

Billing Rule

Use covered CPT when criteria met

Report CPT code 76514 (ophthalmic ultrasound, diagnostic; corneal pachymetry) when the policy selection criteria for medical necessity are met.

Code: 76514

Denial Risk

Potential denial for excluded indications

Claims for pachymetry submitted for indications listed as experimental/investigational (e.g., screening for glaucoma without signs/symptoms, keratoconus, Marfan syndrome, etc.) or for pre‑cataract evaluation without documented corneal disease may be denied.

Documentation Required

Refractive surgery plan exclusion check

Before approving coverage for pachymetry related to corneal refractive surgery, confirm whether the member's benefit plan excludes refractive surgery — corneal pachymetry for evaluation of refractive surgery is excluded under plans with those provisions.

Background and Evidence

Ultrasound corneal pachymetry measures corneal thickness by applying an ultrasonic probe to the central cornea after topical anesthesia; it is quick (under 30 seconds per eye) and can be performed by a technician. It is primarily used to evaluate corneal diseases and to assess glaucoma risk.

The Ocular Hypertension Treatment Study (OHTS) found that central corneal thickness <556 microns was a significant risk factor for development of glaucoma among persons with ocular hypertension, but corneal thickness was measured only after study initiation and was not used to guide therapy. OHTS conclusions are therefore limited to persons with elevated IOP and do not establish utility of pachymetry for screening asymptomatic populations or for directing treatment decisions. Additionally, ultrasonic pachymetry is less accurate than videokeratography for diagnosing keratoconus, limiting its utility in that condition.

Study	Key Finding
Ocular Hypertension Treatment Study (OHTS)	Central corneal thickness <556 microns identified as a predictor of glaucoma development in persons with ocular hypertension; corneal thickness measured after study initiation and not used to guide therapy.
Rabinowitz et al. 1998 (Videokeratography vs ultrasonic pachymetry in keratoconus)	Videokeratography more accurate than ultrasonic pachymetry for detecting keratoconus (97.5% vs 86.0% correct classification).