CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Corneal Collagen Cross-Linking (CXL) Coverage Criteria

Defines medical necessity, coverage, and coding for corneal collagen cross-linking using riboflavin and UVA for progressive keratoconus and corneal ectasia after refractive surgery for BCBSRI members; applies to Medicare Advantage and Commercial products with prior authorization requirements.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyCorneal Collagen Cross-Linking (CXL) Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date08|01|2022

Next Review DateN/A

Key ActionObtain prior authorization for Medicare Advantage members (recommended for Commercial) and document progression per defined metrics before performing CXL.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 DIncrease in steepest K defining progression

0.50 DMyopic shift defining progression

0402TCovered CPT code when criteria met

DiscontinuedPhotrexa products discontinuation

Coverage Criteria

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Medically necessary indications

Covered when ALL of the following are met

Eligibility

Indication: Diagnosis of progressive keratoconus or corneal ectasia after refractive surgery
Conservative treatment (e.g., spectacle correction or rigid contact lens) has failed
Progression criteria (any one): Increase of ≥1 D in the steepest keratometry value OR increase of ≥1 D in regular astigmatism by subjective manifest refraction OR myopic shift (decrease in spherical equivalent) of ≥0.50 D on subjective manifest refraction OR decrease ≥0.1 mm in back optical zone radius in rigid contact lens wearerssee definitions
Documentation should support progression using these metrics

Not medically necessary / Not covered indications

Not covered/Not medically necessary: Corneal collagen cross-linking using riboflavin and ultraviolet A is not covered for Medicare Advantage Plans and is considered not medically necessary for Commercial Products for all indications other than progressive keratoconus or corneal ectasia after refractive surgery when the coverage criteria above are met

Evidence is insufficient to determine the effects of the technology on health outcomes for other indications

For Medicare Advantage members, corneal collagen cross-linking (CXL) requires prior authorization and is covered only when the medical necessity criteria for progressive keratoconus or post‑refractive surgery corneal ectasia are met. For Commercial products, CXL is considered medically necessary for the same indications when the criteria are satisfied; prior authorization is recommended for participating providers.

CXL using riboflavin and ultraviolet A is not covered for Medicare Advantage Plans and is considered not medically necessary for Commercial Products for all indications other than progressive keratoconus or corneal ectasia following refractive surgery after failure of conservative treatment. The evidence is insufficient to support CXL for these other indications.

Coding

Covered CPT CodesCPTCovered

0402T

Collagen cross-linking of cornea, including removal of the corneal epithelium, when performed, and intraoperative pachymetry, when performed

Progression criteria thresholds — K increase, astigmatism, myopic shift, corneal thickness change

Increase in steepest keratometry (K)Increase of ≥1.0 diopter (D) in the steepest keratometry value

Increase in regular astigmatismIncrease of ≥1.0 D in regular astigmatism by subjective manifest refraction

Myopic shift (spherical equivalent)Myopic shift (decrease in spherical equivalent) of ≥0.50 D on subjective manifest refraction

Back optical zone radius decreaseDecrease of ≥0.1 mm in back optical zone radius in rigid contact lens wearers when other information unavailable

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Medicare Advantage Plans and is recommended for Commercial Products (use the payer online tool for participating providers). Failure to obtain prior authorization for Medicare Advantage may result in denial of payment.

Applies to Medicare Advantage Plans (required).
Recommended for Commercial Products via the payer online tool for participating providers.

Documentation Required

Conservative Treatment Failure Required

Corneal collagen cross-linking (CXL) is covered only for treatment of progressive keratoconus or corneal ectasia after failure of conservative treatment such as spectacle correction or rigid contact lenses. CXL is considered medically necessary when the documented progression criteria are met.

Conservative treatment failure required (e.g., spectacles or rigid contact lenses).

Documentation Required

Required Clinical Documentation to Demonstrate Progression

Documentation must demonstrate objective progression of keratoconus or corneal ectasia with one or more of the following: an increase of ≥1.0 diopter (D) in the steepest keratometry value; an increase of ≥1.0 D in regular astigmatism on subjective manifest refraction; a myopic shift (decrease in spherical equivalent) of ≥0.50 D on subjective manifest refraction; or a decrease ≥0.1 mm in the back optical zone radius in rigid contact lens wearers when other information is not available.

Increase of ≥1.0 D in steepest keratometry.
Increase of ≥1.0 D in regular astigmatism on manifest refraction.
Myopic shift (spherical equivalent) decrease of ≥0.50 D on manifest refraction.
Decrease ≥0.1 mm in back optical zone radius for rigid contact lens wearers.

Denial Risk

Not Covered Indications

CXL is not covered for Medicare Advantage Plans and is considered not medically necessary for Commercial Products for indications other than progressive keratoconus or corneal ectasia after failed conservative treatment.

Not covered / not medically necessary for all other indications beyond the specified progressive conditions.

Definitions

Progressive keratoconus or corneal ectasia — definition with metric options (K, astigmatism, myopic shift, thickness)

Definition summaryProgressive keratoconus or corneal ectasia is defined by one or more of the following metrics

Steepest keratometryAn increase of 1 diopter (D) in the steepest keratometry value

Regular astigmatismAn increase of 1 D in regular astigmatism evaluated by subjective manifest refraction

Myopic shiftA myopic shift (decrease in the spherical equivalent) of 0.50 D on subjective manifest refraction

Back optical zone radiusA decrease ≥0.1 mm in the back optical zone radius in rigid contact lens wearers when other information is not available

Epithelium-off (epi-off) CXL — procedure description and FDA approval status

Procedure descriptionEpithelium-off (epi-off) CXL involves removal of ~8 mm of central corneal epithelium under topical anesthesia to allow riboflavin penetration, followed by riboflavin application and 30 minutes of 370 nm UVA irradiation to induce stromal collagen crosslinking

MechanismRiboflavin and UVA interaction forms reactive oxygen species that create additional covalent bonds between collagen molecules, stiffening the cornea

FDA approval statusCurrently the only CXL treatment approved by the FDA is the epithelium-off method

Safety noteWith appropriate riboflavin absorption and homogeneous light, structures beyond a 400-micron stroma are not exposed to cytotoxic UVA doses

Epithelium-on (epi-on) or transepithelial CXL — method description and non–FDA-approved status

Method descriptionEpithelium-on (epi-on) or transepithelial CXL leaves the corneal epithelium intact (or partially disrupted) and requires longer riboflavin loading time to achieve stromal penetration

FDA approval statusThere are no FDA-approved CXL treatments using the epithelium-on method

Clinical contextEpi-on approaches are under evaluation primarily for corneal stabilization in progressive corneal thinning and post-refractive ectasia

Background

Keratoconus is a progressive bilateral corneal ectasia characterized by corneal thinning and steepening that typically presents in younger patients and may progress over time. Corneal ectasia after refractive surgery presents similarly but occurs postoperatively. Corneal collagen cross-linking with riboflavin and ultraviolet A is intended to stiffen the cornea and slow disease progression; only the epithelium‑off (epi‑off) CXL method is FDA‑approved. Clinical evidence, including randomized trials and systematic reviews, demonstrates improvements in corneal curvature and corrected distance visual acuity and a reduction in progression for appropriately selected patients.

Revision History

2026-04-15Policy reviewLatest

Policy last reviewed on April 15, 2026 (clinical content reviewed).

2022-08-01Policy effective

Policy effective date established as August 1, 2022.

2026-01-20Product market change noted

Photrexa products planned to be discontinued from the market effective January 20, 2026 (manufacturing set to end February 2026).

2026-06Publication

Provider Update published in June 2026 referencing the policy.

2025-07Publication

Provider Update published in July 2025 referencing the policy.

2024-06Publication

Provider Update published in June 2024 referencing the policy.

2023-05Publication

Provider Update published in May 2023 referencing the policy.

2022-06Publication

Provider Update published in June 2022 referencing the policy.