CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Phototherapeutic Keratectomy (PTK)

Defines medical necessity and noncoverage criteria for phototherapeutic keratectomy (PTK) for Medicare Advantage and Commercial products, specifies covered CPT code(s) and covered diagnoses, and notes exclusions and alternatives.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPhototherapeutic Keratectomy (PTK)

Policy CodePolicy N/A

Change TypeClarified coverage distinctions (no material change)

Effective DateN/A

Next Review DateN/A

Key ActionDocument that PTK is being used as an alternative to lamellar keratoplasty for corneal scars, opacities, or dystrophies extending beyond the epithelial layer and that medical approaches have been exhausted where applicable.

POLICY UPDATE CHANGES

No material changes — policy updated to clarify coverage distinctions but no material change to clinical/coverage determinations.

1Covered CPT code

2Covered ICD-10 ranges

3Noncovered indications listed

Coverage Summary

Scope: Defines medical necessity and noncoverage criteria for phototherapeutic keratectomy (PTK) for Medicare Advantage and Commercial products, specifies covered CPT code(s) and covered diagnoses, and notes exclusions and alternatives. Coverage stance: mixed — the policy permits PTK as a covered alternative to lamellar keratoplasty for deeper corneal disease (visual impairment or irritative symptoms from corneal scars, opacities, or dystrophies extending beyond the epithelial layer) but explicitly excludes use as an alternative to superficial mechanical keratectomy for superficial disorders and lists additional noncovered/not medically necessary applications.

Covered indications (summary): PTK may be used as an alternative to lamellar keratoplasty for corneal scars, opacities, or dystrophies that extend beyond the epithelial layer. Key exclusions: PTK is not covered as an alternative to superficial mechanical keratectomy for superficial corneal dystrophy, epithelial basement membrane/epithelial membrane dystrophy, or irregular corneal surfaces due to Salzmann's nodular degeneration or keratoconus nodules; PTK is also not covered/not medically necessary for other applications including, but not limited to, treatment of recurrent corneal erosions and infectious keratitis.

Medical Necessity Criteria

Medicare Advantage Plans and Commercial Products - Medically Necessary

Phototherapeutic keratectomy may be considered medically necessary when ALL of the following are met:

ALL of the following

Used as an alternative to a lamellar keratoplasty
Treatment of visual impairment or irritative symptoms related to corneal scars, opacities, or dystrophies extending beyond the epithelial layer

Commercial Products - Not Medically Necessary

Phototherapeutic keratectomy is considered not medically necessary when ANY of the following apply:

ANY of the following

Used as an alternative to a superficial mechanical keratectomy in treating patients with superficial corneal dystrophy, epithelial membrane dystrophy, or irregular corneal surfaces due to Salzmann's nodular degeneration or keratoconus nodules
Used for other applications including, but not limited to, treatment of recurrent corneal erosions and infectious keratitis (evidence insufficient to determine effects on health outcomes)

Medicare Advantage Plans - Not Covered

Phototherapeutic keratectomy is considered not covered when ANY of the following apply:

ANY of the following

Used as an alternative to a superficial mechanical keratectomy in treating patients with superficial corneal dystrophy, epithelial membrane dystrophy, or irregular corneal surfaces due to Salzmann's nodular degeneration or keratoconus nodules
Used for other applications including, but not limited to, treatment of recurrent corneal erosions and infectious keratitis (evidence insufficient to determine effects on health outcomes)

Provider Actions

Documentation Required

Document indication and alternative considered

Document that PTK is being used as an alternative to lamellar keratoplasty and that the treated condition involves corneal scars, opacities, or dystrophies extending beyond the epithelial layer. Also document that medical approaches have been exhausted where applicable (e.g., conservative therapy for recurrent erosions, contact lens management for keratoconus).

Affected CPT code: S0812
Suggested documentation elements: diagnosis and laterality, clinical description showing disease extends beyond the epithelial layer (e.g., stromal opacities or elevated lesions), prior conservative treatments tried and outcomes (lubricants, patching, bandage contact lens, anterior stromal puncture, rigid contact lens use), justification for choosing PTK over lamellar keratoplasty, operative plan and expected benefit.

Denial Risk

Claims denied/not covered for superficial indications

Claims for PTK used as an alternative to a superficial mechanical keratectomy for superficial disorders are not covered and are at risk for denial. Excluded superficial indications include superficial corneal dystrophy, epithelial membrane (basement membrane) dystrophy/irregular corneal surfaces, and irregular surfaces due to Salzmann's nodular degeneration or keratoconus nodules.

Affected CPT code: S0812

Denial Risk

Claims denied/not covered for other unproven applications

Claims for PTK for other applications not supported by evidence are not covered/not medically necessary and are at risk for denial. Examples explicitly listed as not covered/not medically necessary include treatment of recurrent corneal erosions and infectious keratitis; other unproven uses are likewise excluded.

Affected CPT code: S0812

Background and Evidence

Background: 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 surface. PTK differs from photorefractive keratectomy (PRK) in that PRK treats refractive errors (myopia, astigmatism, hyperopia, presbyopia) and PRK is not covered under this policy.

Procedure and setting: PTK may be performed in the office setting under topical anesthesia. Common complications include refractive errors (most commonly hyperopia), corneal scarring, and glare. FDA labeling therapeutic indications summarized in this policy include superficial corneal dystrophies (e.g., granular, lattice, Reis-Buckler's), epithelial basement membrane dystrophy/irregular corneal surfaces (including Salzmann's degeneration and keratoconus nodules), and corneal scars and opacities (post-traumatic, post-surgical, post-infectious, or secondary to pathology).

FDA therapeutic indications (summary)

IndicationsSuperficial corneal dystrophies (including granular, lattice, Reis-Buckler's); epithelial basement membrane dystrophy/irregular corneal surfaces (e.g., Salzmann's degeneration, keratoconus nodules); corneal scars and opacities (post‑traumatic, post‑surgical, post‑infectious, and secondary to pathology).

Reference trial

Prospective multicenter trialAm J Ophthalmol 1996: A prospective multicenter trial of excimer laser PTK for corneal vision loss (Summit Phototherapeutic Keratectomy Study Group).

Revision History

Provider Update, April 2026clarifiedLatest

Policy distinguishes PTK coverage: considered medically necessary when used as an alternative to lamellar keratoplasty for visual impairment or irritative symptoms related to corneal scars, opacities, or dystrophies extending beyond the epithelial layer; excludes use as an alternative to superficial mechanical keratectomy for superficial corneal disorders and excludes other applications (e.g., recurrent corneal erosions, infectious keratitis) as not covered or not medically necessary due to insufficient evidence. No material change flag set.

Provider Update, March 2025clarified

Clarified indications and distinctions between PTK and PRK; noted PTK may be performed in-office with topical anesthesia and listed FDA therapeutic indications (superficial corneal dystrophies, epithelial basement membrane dystrophy/irregular surfaces, corneal scars and opacities).

Provider Update, April 2024clarified

Reiterated that when PTK removes only the epithelial surface the alternative is superficial mechanical keratectomy, while deeper ablation competing technology is lamellar keratoplasty; candidates should have exhausted medical approaches.

Provider Update, December 2023clarified

Affirmed coverage stance differences for Medicare Advantage and Commercial Products: medically necessary criteria and explicit not-covered / not medically necessary uses.

Provider Update, August 2022clarified

Documented CPT code S0812 as medically necessary for covered diagnoses and listed covered ICD-10 diagnosis code ranges H17.00-H17.9 and H18.00-H18.069.