CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Phototherapeutic Keratectomy (PTK) Coverage Criteria

Policy governing when phototherapeutic keratectomy (PTK) is considered medically necessary or not for Medicare Advantage and commercial products offered by Blue Cross Blue Shield - Rhode Island; affects providers performing PTK and claims adjudicators.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPhototherapeutic Keratectomy (PTK) Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 10, 2018

Next Review DateN/A

Key ActionEnsure conservative treatments have been tried and exhausted prior to PTK and consider alternative procedures where appropriate.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1procedure code listed as medically necessary

H17.00-H17.9covered diagnosis range

H18.00-H18.069covered diagnosis range

2018policy effective year

2023policy last review year

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Coverage Criteria — Phototherapeutic Keratectomy (PTK)

Medically Necessary Indications (Medicare Advantage and Commercial)

Covered when used as an alternative to lamellar keratoplasty for:

Primary covered indication: PTK may be considered medically necessary when used as an alternative to a lamellar keratoplasty in the treatment of visual impairment or irritative symptoms related to corneal scars, opacities, or dystrophies extending beyond the epithelial layer.

Medicare Advantage Plans and Commercial Products

Not Covered / Not Medically Necessary Indications

Not covered / Not medically necessary when used as an alternative to superficial mechanical keratectomy for:

Non-covered superficial indications: Superficial corneal dystrophy, epithelial membrane (basement membrane) dystrophy, and irregular corneal surfaces due to Salzmann's nodular degeneration or keratoconus nodules.

Medicare Advantage Plans and Commercial Products - insufficient evidence

Other not covered applications: All other applications, including but not limited to treatment of recurrent corneal erosions and infectious keratitis, are not covered / not medically necessary due to insufficient evidence of health outcome benefit.

Medicare Advantage Plans and Commercial Products

Photorefractive keratectomy (PRK) is a refractive procedure that uses an excimer laser to correct refractive errors (e.g., myopia, hyperopia, astigmatism, presbyopia) and is explicitly not a covered benefit under this policy.

All other uses not addressed in this policy are considered not medically necessary or not covered due to insufficient evidence to determine a health outcome benefit.

For Commercial Products, phototherapeutic keratectomy (PTK) is considered not medically necessary when used as an alternative to superficial mechanical keratectomy for superficial corneal dystrophy, epithelial membrane (basement membrane) dystrophy, irregular corneal surfaces due to Salzmann's nodular degeneration, and keratoconus nodules. Other applications, including treatment of recurrent corneal erosions and infectious keratitis, are also considered not medically necessary because the evidence is insufficient to determine effects on health outcomes.

Coding — Procedure and Diagnosis Codes

Covered CPT/HCPCS CodesHCPCSCovered

S0812

Phototherapeutic keratectomy (PTK)

Covered Diagnosis CodesICD-10Covered

H17.00-H17.9	Corneal scars and opacities (ICD-10 code range)
H18.00-H18.069	Other disorders of cornea (ICD-10 code range)

Provider Actions and Requirements

Prior Authorization

Prior authorization and applicable procedure code

Prior authorization: Not applicable for this policy. CPT code S0812 (phototherapeutic keratectomy) is listed as medically necessary when performed for a covered diagnosis; verify coding and member coverage prior to billing.

Prior authorization: Not required for this policy
Affected code: CPT S0812

Denial Risk

Denial triggers for non-covered indications

PTK is considered not covered / not medically necessary when used as an alternative to superficial mechanical keratectomy for superficial corneal dystrophy, epithelial membrane dystrophy, and irregular corneal surfaces due to Salzmann's nodular degeneration or keratoconus nodules. Other applications (including treatment of recurrent corneal erosions and infectious keratitis) are also considered not covered / not medically necessary when evidence is insufficient to demonstrate clinical benefit.

Background — Procedure Description

Phototherapeutic keratectomy (PTK) uses an excimer laser to sequentially ablate uniformly thin layers of anterior corneal tissue to remove anterior stromal opacities or elevated corneal lesions while maintaining a smooth corneal surface. PTK is intended to treat visual impairment or irritative symptoms related to anterior corneal disease. It is distinct from photorefractive keratectomy (PRK), which is performed to correct refractive errors and is not covered. Candidates for PTK should have exhausted conservative medical therapies (for example, lubricants, patching, bandage contact lenses, anterior stromal punctures for recurrent erosions, or rigid contact lenses for keratoconus) and consider competing procedures such as mechanical superficial keratectomy or lamellar keratoplasty where appropriate.

Definitions

Phototherapeutic Keratectomy (PTK)

TermPhototherapeutic Keratectomy (PTK)

DefinitionUse of the excimer laser to sequentially ablate uniformly thin layers of anterior corneal tissue to treat visual impairment or irritative symptoms from anterior corneal disease by removing anterior stromal opacities or elevated corneal lesions while maintaining a smooth corneal surface.

SettingMay be performed in the office setting under topical anesthesia.

Distinct fromNot the same as photorefractive keratectomy (PRK), which corrects refractive errors and is not covered under this policy.

Potential complicationsInduced refractive error (commonly hyperopia), corneal scarring, and glare.

Photorefractive Keratectomy (PRK)