Prior authorization required when coverage criteria apply

Prior authorization expectation: Providers should obtain prior authorization when CPT/HCPCS codes are covered only if selection criteria are met (e.g., amniotic membrane transplantation [AMT], limbal stem cell transplantation). Authorization decisions should reflect that AMT/LSCT are generally indicated for refractory limbal deficiency or specific documented indications rather than first-line therapy.

• Obtain prior auth when codes are covered only with selection criteria met (see CPT/HCPCS lists).
• Authorization should document refractory status and indication (e.g., total loss or hypofunction of limbal stem cells).

Prior authorization recommended for advanced/complex procedures

Prior authorization recommended for advanced procedures: For complex, bilateral, or combined procedures (for example bilateral severe LSCD, allogeneic stem-cell approaches, multi-layer or combined AMT with keratoplasty), prior authorization is recommended to allow review of medical necessity and documentation (including immunosuppression plans for allografts).

• Consider prior auth for allogeneic LSCT, combined LSCT+PKP, or multi-stage reconstructions.
• Document planned systemic immunosuppression for allo-transplants.

No explicit prior-authorization rules in clinical background

Prior authorization: none specified in these background sections — the CPB contains clinical background and evidence summaries but does not list explicit plan-specific prior authorization rules in every subsection. Providers must consult the member's plan benefits and prior authorization procedures for operational requirements.

• Clinical sections summarize evidence but do not replace plan-level prior authorization rules.
• Check the payer's prior authorization portal or contact medical policy operations for current requirements.

Prior authorization guidance and role of the Clinical Policy Bulletin

Prior authorization guidance: Consult plan benefits and the payer-specific prior authorization process. The Clinical Policy Bulletin is a guide to medical necessity and evidence and may assist adjudication but is not a substitute for plan-specific documentation or contract language.

• Use the CPB to support medical necessity rationale when requesting authorization.
• Verify benefit coverage, submission forms, and required clinical fields prior to submission.

Infection-control considerations for AMT

Appropriateness relative to infection control: AMT is supported as an adjunct when infection is controlled and a persistent epithelial defect remains; using AMT while infection is uncontrolled or outside recommended adjunctive contexts may not align with AAO guidance and can be a denial trigger.

• AAO: if infection is under control and a persistent epithelial defect exists, AMT may be considered as adjunctive therapy.
• Avoid AMT as primary therapy when active infection is uncontrolled; document infection control measures and timing.

Evidence limitations that may impact authorization

Evidence limitations may affect coverage decisions: Randomized trials and systematic reviews provide mixed and sometimes low- or very-low-certainty evidence for certain indications (e.g., severe ocular burns); limitations such as small sample sizes, bias, and imprecision should be considered when assessing medical necessity.

• GRADE downgrades for bias and imprecision reported in ocular burn RCTs; benefit for severe burns is uncertain.
• Document rationale when authorizing AMT for indications with limited or low-certainty evidence.

Role and limits of the Clinical Policy Bulletin

Clinical Policy Bulletins constitute partial plan guidance: CPBs assist in administering plan benefits but are not guarantees of coverage and do not replace contract language or specific benefit documents. Providers are responsible for treatment decisions and must supply required documentation for authorization and claims.

• CPB = guidance only; verify contract/benefit terms for the member.
• Treating providers are responsible for medical decisions; include CPB references to support, not replace, clinical documentation.

Required clinical documentation to support medical necessity

Clinical documentation to support necessity: Authorization and medical-record requests should demonstrate limbal deficiency (clinical findings or impression cytology), refractory status to conventional therapy, prior treatments tried, laterality, and objective findings supporting the indication.

• Document diagnosis (e.g., total loss vs hypofunction of limbal stem cells) and objective evidence (conjunctival epithelial ingrowth, impression cytology if available).
• List prior conservative and medical therapies and duration, and provide photos or exam findings.

Recommended outcome and follow-up documentation

Recommended outcome documentation: For approved procedures, include pre- and post-procedure measures such as visual acuity, corneal surface stability (epithelialization), presence/extent of neovascularization, and need for subsequent interventions in follow-up notes.

• Capture baseline VA and post-op VA at defined intervals.
• Document corneal epithelial status, stability, and any additional procedures (e.g., PKP) performed.

Suggested clinical documentation checklist for authorization requests

Suggested clinical documentation (administrative items to include): Indication, laterality (one or both eyes), prior therapies attempted and duration, objective exam findings (epithelial defect, vascularization), diagnostic test results, proposed procedure details, and planned post-op management (including immunosuppression for allografts).

• Include operative plan, graft type (AM single-layer vs multi-layer; autograft vs allograft), and justification for choice.
• For allografts, document donor source and systemic immunosuppression strategy.

Conservative therapy required before AMT for conjunctivochalasis

Conservative therapy before AMT for conjunctivochalasis: AMT for conjunctivochalasis is considered medically necessary only after conservative treatments (e.g., artificial tears, topical antibiotic/steroid drops) have failed—document attempts and response prior to authorization.

• Document duration and response to conservative measures such as lubricants and anti-inflammatories.
• Include reason conservative care was insufficient.

Stepwise care and step-therapy context before AMT

Step therapy and stepwise care context: While no formal step-therapy algorithm is mandated in these clinical sections, common practice and guideline-consistent care require stepwise escalation—maximal medical therapy for dry eye/NK or initial antimicrobial therapy for infectious keratitis—before considering AMT as adjunctive or reconstructive therapy.

• For infectious keratitis, document appropriate antimicrobial therapy and evidence of infection control prior to AMT.
• For dry eye/neurotrophic keratopathy, document failure of maximal medical treatments (e.g., tears, cyclosporine, serum) before CAM/AMT.