Currentblue cross blue shield - michiganPolicy MAPPO 1020

Laser-assisted in situ keratomileusis (LASIK) and radial keratotomy benefits

Defines Medicare Plus Blue Group PPO coverage, payment, billing and member cost-share rules for laser-assisted in situ keratomileusis (LASIK) and radial keratotomy for applicable members and providers.

Policy Summary

Payerblue cross blue shield - michigan

PolicyLaser-assisted in situ keratomileusis (LASIK) and radial keratotomy benefits

Policy CodePolicy MAPPO 1020

Change TypeRevised — coverage applicability update

Effective Date01/01/2026

Next Review DateDec 6, 2024

Key ActionVerify member benefits and cost-share via the provider portal or call 1-866-309-1719 before delivering services.

SourceLink

POLICY UPDATE CHANGES

Updated the policy paper to remove coverage for individual member's going back to 01/01/2026.

5 codesListed billable procedure codes for payment

H52.xAllowed diagnosis codes

NoneAge limitations for payment

ExcludedCost-share exclusion from MOOP

Not covered

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Coverage and Medical Necessity

Coverage and operational criteria

Coverage is provided to members under select Medicare Plus Blue Group PPO plans subject to group-determined scope, payment, and member cost sharing. The following operational criteria and billing instructions apply.

ALL of the following

Covered only for members enrolled in select Medicare Plus Blue Group PPO plans; Original Medicare does not cover LASIK or radial keratotomy.
Scope, reimbursement, maximum payment amounts and member cost sharing are determined by the group for group-based coverage.

ALL of the following

Eligible providers: M.D., D.O., ophthalmologist, or optometrist.
Payable locations: no restrictions.

ALL of the following

Report CPT/HCPCS and diagnosis codes to the highest level of specificity.
Permitted procedure codes (examples)
- S0800 (Laser-assisted in situ keratomileusis).
- 65771 (Radial keratotomy or related corneal procedure).
- 76514; 92025; 92134 (ancillary ocular imaging/diagnostic codes).
Allowed diagnosis ranges: H52.0–H52.03; H52.1–H52.13; H52.2–H52.229.

ALL of the following

Provider will be paid the lesser of the allowed amount or the provider's charge, minus the member's cost share.
Maximum payment amounts are published on the MA enhanced benefits fee schedule on the provider website.
This payment represents payment in full; providers are not allowed to balance bill the member for the difference.

ALL of the following

Collect applicable Medicare Plus Blue cost sharing (copayment, coinsurance or deductible) from the member at time of service when possible.
If a member elects to receive a noncovered service, the member is responsible for the entire charge; providers may not have members sign an ABN for these services.
Cost-share amounts under this benefit do not count toward the plan deductible or the combined maximum out-of-pocket for individual members.
To verify benefits and member cost-share, providers should use the provider portal or call 1-866-309-1719.

ALL of the following

Bill services on the CMS 1500 (02/12) claim form or the 837 equivalent; use Medicare Advantage PPO unique billing requirements.
Report National Provider Identifier (NPI) on all claims and submit to the local Blue Cross plan; use electronic billing (ANSI ASC X12N 837/835) per local EDI guidance.
When billing pre-operative evaluation and management services, append modifier 57 to the E/M service that resulted in the initial decision to perform surgery.

ALL of the following

No age restrictions for payment under these Medicare Plus Blue benefits.
Providers may not balance bill members; seek a coverage determination from Blue Cross if coverage is uncertain prior to providing services.

ALL of the following

Benefit scope, reimbursement methodology, maximum allowed payments and member cost sharing are determined by the employer/group for group-based coverage; verify applicability for individual members.
Operational change effective 01/01/2026 removes coverage for individual members (see policy changes).
Material policy change; confirm member-specific applicability prior to service delivery.

Permitted Procedure and Payment Codes

Permitted CPT/HCPCS codesmixedCovered

S0800	Laser-assisted in situ keratomileusis
65771	Radial keratotomy or related corneal procedure
76514	Ocular ultrasound
92025	Ophthalmological services: visual field examination
92134	Ophthalmic imaging (OCT)

Payment methodology

Payment calculationProvider paid the lesser of the allowed amount or the provider’s charge, minus the member’s cost share.

Reference for maximum paymentsMA enhanced benefits fee schedule on provider website: bcbsm.com/amslibs/content/dam/public/providers/documents/medicare-plus-blue-feeschedule.pdf.

Balance billing prohibitionThis payment represents payment in full; providers aren’t allowed to balance bill the member for the difference between the allowed amount and the charge.

Member cost-share handlingCollect applicable member cost share; the member’s cost share is subtracted from the payment calculation.

Provider Billing, Verification, and Authorization

Documentation Required

Verify benefits, collect appropriate cost-share, and obtain coverage determinations

Coverage for LASIK and radial keratotomy is available only for members under select Medicare Plus Blue Group PPO plans; because Original Medicare does not cover these procedures, the group determines benefit scope, reimbursement methodology, maximum payment amounts, and member cost sharing. Providers must verify member benefits and the applicable cost-share prior to providing services by using the provider portal or calling 1-866-309-1719. Collect the appropriate Medicare Plus Blue cost-sharing amount at the time of service when possible, and do not have members sign an ABN for these services — if coverage is uncertain, obtain a coverage determination from Blue Cross before delivering the service.

Verify eligibility, benefit scope, reimbursement limits and member cost-share via the provider portal or by calling 1-866-309-1719 before delivering services.
Collect only the applicable Medicare Plus Blue cost-sharing (copayment, coinsurance, or deductible) at time of service when possible.
Do not have members sign an Advance Beneficiary Notice (ABN) for these services; if coverage is unclear, obtain a Blue Cross coverage determination first.
If a member elects a noncovered service without a prior coverage determination, the member is responsible for the charge, but the provider must hold the member harmless except for any applicable cost share.

Definitions

LASIK

DefinitionLASIK is a refractive keratoplasty procedure that permanently changes the shape of the cornea by creating a corneal flap with a microkeratome, folding the flap to expose the stroma, and using computer-controlled laser pulses to vaporize a portion of the stroma before replacing the flap.

Procedure componentsCreation of a corneal flap (microkeratome with hinge), laser ablation of stromal tissue, and flap repositioning.

PurposeTo change the refractive index of the corneal surface to improve vision and correct refractive error.

Radial keratotomy

DefinitionRadial keratotomy is a surgical correction for myopia in which the physician places precise microincisions (usually eight or fewer) on the corneal surface in a spoke-like pattern to flatten the central cornea and reduce refractive error.

Technique details