MA Keratoplasty (Preauthorization Required)
Customize your policy alerts
Sign up for Blue Cross Blue Shield - Nebraska Policy M.62 alerts
Get alerted when Policy M.62 changes without checking for updates manually.
Monitor payer policy activity
Defines medical necessity and preauthorization requirements for corneal collagen cross-linking, intrastromal corneal ring segments (INTACS), deep anterior lamellar keratoplasty (DALK), and full-thickness penetrating keratoplasty; applies to providers seeking coverage from Blue Cross Blue Shield - Nebraska.
No material clinical or coverage changes in this revision.
Coverage Criteria for Corneal Procedures
Corneal Collagen Cross-Linking (CXL)
Services may be considered reasonable and necessary when ALL of the following are met:
CXL overall
- Progression evidence: One or more of: keratoconus surgical treatment OR increase >=1.00 D in steepest keratometry OR increase in mean keratometry >=0.7 D OR thinning of corneal pachymetry >=10 microns OR reduction in uncorrected or best spectacle-corrected visual acuity by >1 linetimeframe: within preceding 12 months
From policy text
Intrastromal Corneal Ring Segments (INTACS)
Services may be considered reasonable and necessary when ALL of the following are met:
All listed conditions required
Deep Anterior Lamellar Keratoplasty (DALK)
Services may be considered reasonable and necessary when ALL of the following are met:
Both conditions required
Full Thickness Corneal Transplantation (Penetrating Keratoplasty)
Services may be considered reasonable and necessary when:
Policy reserves PK when alternatives fail or are not indicated; other indications are generally medically necessary
Penetrating keratoplasty performed for indications other than keratoconus — for example, corneal degeneration or dystrophies, infectious or noninfectious keratitis, and traumatic corneal injury — is generally considered medically necessary and is not subject to the keratoconus-specific criteria in this policy. These non-keratoconus indications should be evaluated and authorized based on their clinical presentation and standard surgical indications rather than the progression thresholds listed for keratoconus-directed procedures.
Procedures that do not meet the specific clinical criteria listed for each corneal intervention are generally considered not medically necessary. Examples include performing corneal collagen cross-linking (CXL) when documented progression criteria are absent or when corneal pachymetry is below the policy threshold of 400 microns. Similarly, INTACS, DALK, or penetrating keratoplasty requests that lack the required age, progression, thickness, anatomic, or prior-treatment findings may be denied as not meeting the policy’s reasonable-and-necessary conditions.
Coding and Thresholds
| 0402T | COLLAGEN CROSS-LINKING OF CORNEA (INCLUDING REMOVAL OF THE CORNEAL EPITHELIUM AND INTRAOPERATIVE PACHYMETRY WHEN PERFORMED) |
| 65710 | KERATOPLASTY ANTERIOR LAMELLAR |
| 65730 | KERATOPLASTY PENETRATING (except in aphakia or pseudophakia) |
| 65750 | KERATOPLASTY PENETRATING (in aphakia) |
| 65755 | KERATOPLASTY PENETRATING (in pseudophakia) |
| 65756 | KERATOPLASTY ENDOTHELIAL |
| 65757 | BACKBENCH PREPARATION OF CORNEAL ENDOTHELIAL ALLOGRAFT |
| 65785 | IMPLANTATION OF INTRASTROMAL CORNEAL RING SEGMENTS |
Preauthorization and Documentation Requirements
Obtain preauthorization for keratoplasty and related corneal procedures
Preauthorization is required for keratoplasty and related corneal procedures; requests must meet the listed clinical criteria for the specific procedure. Covered CPT codes include 0402T and the 6571x–6578x series listed in the policy and should be included with the authorization request.
Document prior treatments and failure or contraindication before DALK/PK (and INTACS conditions)
Other, less-invasive treatments must have failed or be contraindicated before proceeding to DALK or penetrating keratoplasty; similarly, INTACS is covered only when corneal transplantation is the only alternative to improve vision.
- DALK: "Other treatment options (eg. conventional CXL, Intacs) have failed or are not indicated."
- PK: "Other treatment options (eg. conventional CXL, Intacs, DALK) have failed or are not indicated."
- INTACS: covered only when "Corneal transplantation is the ONLY alternative to intrastromal corneal ring segments for improving vision."
Include required clinical documentation with preauthorization
Include objective clinical documentation with preauthorization requests: diagnosis, measures of progression, corneal thickness at proposed treatment time/site, prior therapies and outcomes, and the CPT code(s) being requested.
- Diagnosis (e.g., progressive keratoconus) and specific procedure requested
- Objective evidence of progression within preceding 12 months (e.g., increase ≥1.00 D in steepest keratometry, mean keratometry increase ≥0.7 D, pachymetry thinning ≥10 microns, reduction in VA >1 line, or prior keratoconus surgical treatment)
- Corneal pachymetry: ≥400 microns at time of CXL; ≥450 microns at proposed INTACS incision site
- Clear central cornea when required by procedure
- Prior therapies attempted and outcomes (e.g., CXL, INTACS, contact lens/GL correction attempts)
- Applicable CPT code(s) from policy (e.g., 0402T, 65710, 65730, 65750, 65755, 65756, 65757, 65785)
Denial risk if medical necessity criteria are not met
Requests that do not meet the policy's medical necessity criteria are likely to be denied—examples include CXL without documented progression or insufficient pachymetry, INTACS when transplantation is not the only alternative, or keratoplasty when prior treatments have not failed and are indicated.
- CXL denials: lack of documented progressive keratoconus within prior 12 months or corneal thickness <400 microns at time of treatment
- INTACS denials: patient <21 years, inadequate documentation of progressive vision deterioration, inadequate trial of non-surgical correction, or when corneal transplantation is not the only alternative
- DALK/PK denials: absence of documentation that other treatment options have failed or are not indicated
Background and Clinical Context
Keratoplasty encompasses a range of corneal transplant and restorative procedures intended to restore vision, relieve pain, and preserve ocular integrity in advanced corneal disease. Modern practice favors layer-specific (lamellar) approaches when feasible — for example, Deep Anterior Lamellar Keratoplasty (DALK) to replace anterior stromal disease while preserving a healthy endothelium — because lamellar techniques reduce rejection risk and can improve outcomes. Full-thickness penetrating keratoplasty (PK) is reserved for cases with full-thickness pathology or when less invasive options have failed or are not indicated. Preoperative selection should prioritize the least invasive effective procedure and document why alternatives (e.g., conventional CXL, INTACS, DALK) are unsuitable or have failed when proceeding to lamellar or penetrating transplantation.
Definitions of Procedures
Policy Revision History
Policy became effective as written on 2026-06-01.
Policy underwent review on 2026-03-25.
Next policy review scheduled for 2027-02-03.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.