CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Implantation of Intrastromal Corneal Ring Segments

Defines medical coverage criteria and coding for implantation of intrastromal corneal ring segments for keratoconus and states noncoverage for myopia and other indications; applies to Medicare Advantage and Commercial products of Blue Cross Blue Shield - Rhode Island.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyImplantation of Intrastromal Corneal Ring Segments

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2016

Next Review DateN/A

Key ActionObtain prior authorization (required for Medicare Advantage; recommended for Commercial) via the online tool when criteria are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

21+minimum patient age

>=450μmminimum corneal thickness

65785covered CPT code

2016-01-01effective date

02-01-2023policy last updated

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria

Medically necessary for keratoconus

Covered when ALL of the following are met:

Kerotoconus coverage criteria: Patient has keratoconus and meets all of: age >= 21 years; progressive deterioration in vision such that adequate functional vision cannot be achieved with contact lenses or spectacles on a daily basis; corneal transplantation is the only remaining option to improve functional vision; clear central cornea; corneal thickness >= 450 microns at the proposed incision site.age >= 21 years; corneal thickness >= 450 microns

Prior authorization is required for Medicare Advantage and recommended for Commercial Products; obtained via the online tool for participating providers.

Not covered / insufficient evidence

Not covered or considered not medically necessary for other indications:

Other indications: Implantation of intrastromal corneal ring segments (ICRS) is not covered for indications other than keratoconus (Medicare Advantage) and is considered not medically necessary for all other conditions (Commercial) because the evidence is insufficient to determine effects on health outcomes.

Includes pellucid marginal degeneration and astigmatism after penetrating keratoplasty where evidence is insufficient; many case series used devices not available in the U.S.

Contract exclusion

Myopia exclusion: ICRS implantation is a contract exclusion and is not covered when performed as a treatment of myopia.

Procedure may be denied if used to treat myopia (contract exclusion).

Implantation of intrastromal corneal ring segments (ICRS) as a treatment for myopia is a contract exclusion and is not covered under this policy.

For Commercial Products, implantation of intrastromal corneal ring segments is considered not medically necessary for indications other than keratoconus because the evidence is insufficient to determine the effect of the technology on health outcomes.

Coding

Covered CPT CodesCPTCovered

65785

Implantation of intrastromal corneal ring segments

inv-07: Minimum corneal thickness at incision site — clinical threshold

Minimum corneal thickness at proposed incision site>= 450 microns

Measurement locationThickness specified at the proposed incision site (central cornea must be clear)

Documentation requirementClinical record must document corneal thickness >= 450 microns at the proposed incision site

inv-08: Minimum patient age — clinical threshold

Minimum patient age for coverage>= 21 years

Age basisApplies to patients 21 years of age or older for keratoconus indication

Provider Actions & Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Medicare Advantage Plans and recommended for Commercial Products; obtain prior authorization via the web-based online tool for participating providers for the treatment of keratoconus.

Applies to Medicare Advantage Plans (required) and Commercial Products (recommended)
Obtain via the payer's web-based online preauthorization tool

Documentation Required

Conservative Therapy Prior

Conservative management such as rigid gas permeable or hard contact lenses is the usual initial treatment for keratoconus prior to considering implantation of intrastromal corneal ring segments (ICRS). Penetrating keratoplasty or other surgical alternatives are considered when contact lenses or spectacles no longer provide adequate functional vision.

Initial treatment: hard or rigid gas permeable contact lenses

Background

Keratoconus is a progressive bilateral corneal ectatic disorder characterized by paracentral steepening and stromal thinning that produces irregular astigmatism and impaired visual acuity. Intrastromal corneal ring segments (ICRS) are microthin, removable implants placed in peripheral corneal channels to flatten and regularize the anterior cornea. ICRS aim to improve functional vision and may delay or avoid the need for corneal transplantation in appropriate patients.

Definitions

inv-16: Intrastromal corneal ring segments (ICRS) — device definition and purpose.

DefinitionMicrothin soft plastic inserts of variable thickness placed in peripheral corneal channels to change corneal shape by flattening the anterior cornea

Insertion techniqueInserted through a corneal incision into lamellar channels created manually or with a femtosecond laser; one or two segments per channel

ReversibilityImplants can be removed or replaced at a later date if required

PurposeIntended to regularize/flatten the cornea to restore functional vision and potentially defer corneal transplantation in keratoconus

inv-17: Keratoconus — disease definition.

DefinitionProgressive bilateral dystrophy characterized by paracentral steepening and stromal thinning that impairs visual acuity