CurrentBlue Cross Blue Shield - MassachusettsPolicy 675

Corneal Refractive and Keratoplasty Procedures (Epikeratophakia)

Defines medical necessity, investigational status, coding, and prior authorization requirements for corneal refractive and keratoplasty procedures for Blue Cross Blue Shield Massachusetts members.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyCorneal Refractive and Keratoplasty Procedures (Epikeratophakia)

Policy CodePolicy 675

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain pre-service authorization for all inpatient procedures; verify outpatient prior authorization requirements by commercial product.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1CPT covered

4Investigational procedures

4Related policies

H27.*, Q12.3Diagnosis codes

Coverage Determinations

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Epikeratophakia (CPT 65767) may be medically necessary in the treatment of aphakia when medical necessity criteria are met.

Procedures listed as investigational: Keratomileusis (CPT 65760) and Keratophakia (CPT 65765) are considered investigational.

Procedures considered not medically necessary for refractive correction: Automated lamellar keratoplasty, mini-radial keratotomy, LASIK, photorefractive keratectomy (PRK), conductive keratoplasty, and hexagonal keratoplasty are considered not medically necessary to correct refractive disorders.

Lamellar and tectonic keratoplasty for medical indications: Lamellar keratoplasty and tectonic or optic keratoplasty may be medically necessary for conditions such as corneal ulcers or trauma with scar formation.

The policy identifies a set of refractive keratoplasty procedures that are considered not medically necessary when performed for vision correction. These include Automated Lamellar Keratoplasty (ALK), mini‑radial keratotomy (mini‑RK), LASIK for vision correction, photorefractive keratectomy (PRK), conductive keratoplasty, and hexagonal keratotomy. The Description section further explains ALK, mini‑RK, and hexagonal techniques as examples of procedures intended to reshape the cornea to correct hyperopia or myopia.

Specific procedures listed as NOT MEDICALLY NECESSARY to correct refractive disorders include Automated Lamellar Keratoplasty (ALK), mini‑radial keratotomy, LASIK, photorefractive keratectomy (PRK), conductive keratoplasty, and hexagonal keratotomy. The Description provides context on ALK (creation and repositioning of a corneal “cap” to correct hyperopia), mini‑RK (incisional alteration for myopia), and hexagonal keratotomy (patterned incisions for hyperopia and presbyopia).

Codes and Coding Guidance

Covered CPT Codes (when medical necessity met)CPTCovered

65767

Epikeratoplasty

CPT Codes (listed)CPT

65710

Keratoplasty (corneal transplant); anterior lamellar

CPT Codes considered investigationalCPTExperimental

65760	Keratomileusis
65765	Keratophakia
65771	Radial keratotomy

ICD-10 Diagnosis Codes considered medically necessary when submitted with CPT 65767ICD-10

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

Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization Required

Pre-service approval is required for all inpatient services for all products. Outpatient prior authorization requirements vary by commercial product; providers must verify member-specific benefits and authorization rules prior to scheduling outpatient corneal surgery for vision correction.

Pre-service approval required for all inpatient services (all products)
Outpatient prior authorization requirements differ by commercial product — verify member contract

Documentation Required

Coding and Documentation

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 this policy does not guarantee member coverage or provider reimbursement; always confirm coverage under the member's contract at the time of service.

Report services with current CPT, HCPCS, revenue, and ICD-10 codes and appropriate modifiers
Code lists in this policy are informational and not all-inclusive
Verify contract benefits for coverage determinations

Note

Provider Action

Actionable provider note: confirm prior authorization requirements for outpatient procedures with the member's specific commercial product and obtain pre-service approval when required to avoid claim denials or delays.

Check member's product (e.g., HMO/POS vs PPO/Indemnity) for outpatient authorization rules
Obtain and document authorizations prior to performing outpatient services when required

Background

Refractive keratoplasty encompasses surgical procedures that alter corneal shape to correct refractive errors such as myopia and hyperopia. Techniques described in the policy include radial keratotomy variants (including mini‑RK), automated lamellar keratoplasty (ALK), keratomileusis, keratophakia, and epikeratophakia, each with distinct operative approaches and proposed indications (for example, aphakia, keratoconus, or refractive error correction). The policy notes that excimer laser ablation techniques (PRK/laser procedures) and other refractive surgeries may be used to reshape the cornea, while also distinguishing procedures that may be medically necessary for nonrefractive, medical indications (for example, lamellar or tectonic keratoplasty for corneal ulcers or trauma).

Key Definitions

Epikeratophakia — definition and key facts

DefinitionEpikeratophakia is a lamellar keratoplasty technique involving suturing a prelathed donor cornea onto the recipient corneal surface.

Proposed indicationsCorrection of aphakia (adult and pediatric), keratoconus, and myopia.

Procedure typeLamellar corneal transplant (donor tissue applied to corneal surface rather than full-thickness replacement).

Associated CPT code65767 (Epikeratoplasty) — listed as covered when medical necessity criteria are met.

Coverage stanceMay be medically necessary in the treatment of aphakia when medical necessity criteria are met.

Automated Lamellar Keratoplasty (ALK) — definition and key facts

DefinitionAutomated Lamellar Keratoplasty (ALK) is a procedure that creates a corneal 'cap' with an automated instrument; repositioning the cap produces refractive change by microscopic scar formation and cap bulging.

Intended correctionUsed to correct hyperopia (farsightedness); typically treats moderate farsightedness by causing the cap to bulge and reduce corneal flattening.

Technique detailsThe cornea is opened across the top to form a cap which is replaced to adhere by scar formation; procedures are usually done one eye at a time with several weeks between surgeries.

Coverage stanceConsidered NOT MEDICALLY NECESSARY to correct refractive errors (listed among refractive keratoplasty procedures not medically necessary for refraction/accommodation).

Related proceduresOften discussed alongside mini-RK, hexagonal keratotomy, RK, PRK, LASIK as refractive keratoplasties.