CurrentBlue Cross Blue Shield - MassachusettsPolicy 675

Corneal_Surgery_for_Vision_Correction_Policy

This policy describes medical necessity, investigational, and not medically necessary positions for various corneal refractive and keratoplasty procedures for Commercial members (Managed Care HMO/POS, PPO, Indemnity). It lists CPT and ICD-10 codes that are covered when criteria are met, investigational codes, prior authorization guidance for inpatient services, and related notes.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyCorneal_Surgery_for_Vision_Correction_Policy

Policy CodePolicy 675

Change TypeMedicare info removed; 2014 coding & indications clarification

Effective Date

Next Review Date

Key ActionObtain pre-service approval for all inpatient admissions and prior authorization for inpatient services.

SourceLink

POLICY UPDATE CHANGES

Medicare information was removed.

New medically necessary indications described and coding information clarified effective 2014-08-01.

2CPT codes listed as covered when criteria met

3CPT codes listed as investigational

6Procedures listed as not medically necessary

Coverage Summary

This policy covers refractive keratoplasty procedures for Commercial members (Managed Care HMO/POS, PPO, Indemnity). It distinguishes procedures that may be MEDICALLY NECESSARY (for example, Epikeratophakia (CPT 65767) for aphakia and certain lamellar or tectonic keratoplasties such as CPT 65710 anterior lamellar for corneal ulcers or trauma), procedures considered INVESTIGATIONAL for commercial members (including Keratomileusis (CPT 65760), Keratophakia (CPT 65765), and Radial keratotomy (CPT 65771)), and procedures that are NOT MEDICALLY NECESSARY when performed to correct refraction or accommodation (for example, automated lamellar keratoplasty, mini-radial keratotomy, LASIK, PRK, conductive keratoplasty, hexagonal keratoplasty).

Policy metadata and dates - Note: Blue Cross Blue Shield - Massachusetts

policy_number675

subjectCorneal surgery for vision correction (refractive keratoplasty and related procedures)

statusCURRENT

last_review2023-01-01

effective_date

next_review

2CPT codes listed as covered when criteria met (e.g., 65767, 65710)

3CPT codes listed as investigational (65760, 65765, 65771)

6Procedures listed as not medically necessary (ALK, mini-RK, LASIK, PRK, conductive, hexagonal, etc.)

Medical-Necessity Criteria

Medically Necessary Indications

Epikeratophakia may be MEDICALLY NECESSARY in the treatment of aphakia; Lamellar keratoplasty and tectonic or optic keratoplasty may be MEDICALLY NECESSARY for medical conditions such as corneal ulcers or trauma resulting in scar tissue.

ANY of the following

Epikeratophakia for aphakia: Epikeratophakia (CPT 65767) is medically necessary for treatment of aphakia when medical necessity criteria are met.
When billing CPT 65767 submit one of the listed ICD-10 aphakia diagnosis codes (H27.00, H27.01, H27.02, H27.03, Q12.3) to support medical necessity.
Lamellar/tectonic/optic keratoplasty for medical conditions: Lamellar keratoplasty and tectonic or optic keratoplasty (e.g., CPT 65710 anterior lamellar) may be medically necessary for corneal ulcers or trauma resulting in scar tissue.

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Investigational

The following procedures are considered investigational for Commercial Members:

Investigational procedures

Keratomileusis (CPT 65760) — investigational.
Keratophakia (CPT 65765) — investigational.
Radial keratotomy (CPT 65771) — investigational.
Other refractive keratoplasty procedures: All other refractive keratoplasty procedures listed in the Description section of the policy are investigational.

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Not Medically Necessary for Vision Correction

The following procedures to correct disorders of refraction or accommodation are NOT MEDICALLY NECESSARY (including when member has vision care rider):

Not medically necessary procedures for vision correction

Automated lamellar keratoplasty (ALK) — not medically necessary.
Mini-radial keratotomy — not medically necessary.
LASIK for vision correction — not medically necessary.
Tectonic or optic keratoplasty for vision correction: Tectonic or optic keratoplasty (for vision correction) — not medically necessary.
PRK:

Provider Actions & Billing Requirements

Prior Authorization

Pre-service approval for inpatient services

Pre-service approval is required for all inpatient services for all products; providers must obtain prior authorization for inpatient admissions.

Prior authorization required for inpatient admissions for all products

Documentation Required

Submit ICD-10 with CPT 65767

When billing CPT 65767 (Epikeratoplasty) submit one of the listed ICD-10 aphakia diagnosis codes to support medical necessity.

H27.00
H27.01
H27.02
H27.03
Q12.3
CPT 65767

Billing Rule

Code reporting guidance

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable; inclusion of a code in the policy is informational and does not guarantee coverage or reimbursement.

Inclusion of a code is informational and does not guarantee reimbursement
Use current procedure, revenue, and diagnosis codes and modifiers

Background & Definitions

Refractive keratoplasty is a generic term for surgical procedures on the cornea to change its refractive properties. Procedures described include radial keratotomy (RK) — multiple precise microincisions to flatten the central cornea for myopia; excimer laser-based approaches (e.g., PRK) to ablate microscopic tissue with brief ultraviolet pulses for corneal reshaping; and automated lamellar keratoplasty (ALK), which creates and repositions a corneal “cap” to treat hyperopia.

Other procedures include keratomileusis (remove, freeze, lathe, and replace the patient’s cornea) proposed for myopia and aphakic hyperopia; keratophakia (placement of a lathed donor cornea beneath the recipient cornea) proposed for aphakic hyperopia; and epikeratophakia (suturing a prelathed donor cornea onto the recipient surface) proposed for aphakia, keratoconus, and myopia.

Evidence cited in the policy includes TEC assessments: TEC Assessment 1986 and TEC Assessment 1988. Policy history notes Medicare information removal (See MP #132) and coding/ICD-10 formatting updates in 2014.

Refractive keratoplasty: A generic term that includes all surgical procedures on the cornea to improve vision by changing the refractive index of the corneal surface.

Epikeratophakia: Lamellar keratoplasty involving suturing a prelathed donor cornea onto the surface of the recipient's cornea; proposed for correcting aphakia, keratoconus, and myopia.

OpenPayer

Corneal_Surgery_for_Vision_Correction_Policy

Coverage Summary

Medical-Necessity Criteria

Coding

Provider Actions & Billing Requirements

Background & Definitions

Medicare Determinations

Revision History

65767	Epikeratoplasty
65710	Keratoplasty (corneal transplant); anterior lamellar

—	Automated lamellar keratoplasty (ALK) — no specific CPT listed in policy text
—	Mini-radial keratotomy — no specific CPT listed in policy text
—	LASIK — no specific CPT listed in policy text
—	Photorefractive keratectomy (PRK) — no specific CPT listed in policy text
—	Conductive keratoplasty — no specific CPT listed in policy text
—	Hexagonal keratoplasty — no specific CPT listed in policy text

H27.00	Aphakia, unspecified eye
H27.01	Aphakia, right eye
H27.02	Aphakia, left eye
H27.03	Aphakia, bilateral
Q12.3	Congenital aphakia

65760	Keratomileusis
65765	Keratophakia
65771	Radial keratotomy