CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy Corneal Collagen Crosslinking

Defines coverage for corneal collagen cross-linking (riboflavin + UVA) for progressive keratoconus and corneal ectasia after refractive surgery across Commercial products and notes Medicare (BlueCHiP) stance. Includes clinical indications, definitions of progression, coding guidance, and prior authorization recommendation for commercial products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy Corneal Collagen Crosslinking

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug 15, 2017

Next Review Date

Key ActionPrior authorization is recommended for Commercial products via the online tool for participating providers.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes.

2Primary Covered Indications (Commercial)

1Medicare Not Covered (BlueCHiP)

4Progression Criteria Items

Coverage Summary

This policy defines coverage for corneal collagen cross-linking (CXL: riboflavin + UVA). For Commercial products CXL is covered as medically necessary for progressive keratoconus and corneal ectasia after refractive surgery when the specified progression criteria and prior-conservative-treatment requirements are met. For BlueCHiP for Medicare the policy states that CXL (riboflavin and UVA) is not covered for all indications due to insufficient evidence to determine effects on health outcomes.

Coding

Covered CPT (when criteria met) - CommercialCPTCovered

0402T

Collagen cross-linking of cornea, including removal of the corneal epithelium and intraoperative pachymetry, when performed (Report medication separately)

Not Covered CPT - BlueCHiP for MedicareCPTNot Covered

0402T

Collagen cross-linking of cornea, including removal of the corneal epithelium and intraoperative pachymetry, when performed (Report medication separately)

Provider Actions

Prior Authorization

Prior authorization recommended for Commercial products

Prior authorization is recommended for Commercial products via the online tool for participating providers.

Documentation Required

Document progression criteria

Providers should document evidence of progression using at least one of the defined thresholds (increase in steepest keratometry, increase in astigmatism, decrease in back zone radius for rigid contact lens wearers, or optical myopic shift) and document failure of conservative treatment (spectacle correction, rigid contact lens).

Increase in steepest keratometry: >= 1 D
Increase in astigmatism (subjective manifest refraction): >= 1 D
Decrease in back zone radius (rigid contact lens wearers): >= 0.1 mm
Optical myopic shift (spherical equivalent): >= 0.50 D

Background and Evidence

Corneal collagen cross-linking (CXL) is a photochemical procedure using the photosensitizer riboflavin (vitamin B2) and ultraviolet A (UVA) irradiation to stiffen the cornea and potentially slow progression of keratoconus or post-refractive surgery ectasia. Two CXL protocols are described: the epithelium-off method (corneal epithelium removed to permit stromal riboflavin penetration), which is the only FDA-approved CXL technique, and the epithelium-on (transepithelial) method (epithelium left intact), which is not FDA-approved. CXL is evaluated primarily for corneal stabilization in patients with progressive corneal thinning such as keratoconus and corneal ectasia after refractive surgery.

Multiple randomized controlled trials, systematic reviews, and nonrandomized studies have reported results supporting clinically meaningful improvement in net health outcome for patients with progressive keratoconus and for corneal ectasia following refractive surgery after treatment with riboflavin‑UVA CXL.

Progressive keratoconus or corneal ectasia: Presence of one or more objective changes — ≥ 1.0 D increase in steepest keratometry, ≥ 1.0 D increase in astigmatism on subjective manifest refraction (regular), ≥ 0.1 mm decrease in back zone radius (rigid contact lens wearers), or ≥ 0.50 D myopic shift in spherical equivalent.

Epithelium-off CXL: Protocol where the corneal epithelium is removed to allow riboflavin stromal penetration; currently the only FDA‑approved CXL method.

Epithelium-on (transepithelial) CXL: Protocol leaving the epithelium intact (or partially disrupted); not FDA‑approved.