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    v1.0.28
    OpenPayerPolicy UpdatesOphthalmology/OptometryBlue Cross TN corneal CXL Coverage Update | OpenPa…
    Ask Trek AI about this page
    CurrentBlue Cross Blue Shield - TennesseePolicy N/A

    Corneal collagen cross-linking (CXL) — Coverage Criteria

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    Defines medical necessity and investigational use of corneal collagen cross-linking for progressive keratoconus and post‑refractive surgery corneal ectasia for Blue Cross Blue Shield - Tennessee members and providers.

    Policy Summary
    PayerBlue Cross Blue Shield - Tennessee
    PolicyCorneal collagen cross-linking (CXL) — Coverage Criteria
    Policy CodePolicy N/A
    Change TypeMaterial update — added Epioxa™ as acceptable optionPhotrexa® market withdrawal noted
    Effective DateN/A
    Last ReviewJun 30, 2026
    Next Review DateN/A
    Key ActionObtain prior authorization and document indication, prior conservative treatment failure, and the specific CXL product/technique used.
    SourceLink
    POLICY UPDATE CHANGES

    Epioxa™ (epithelium-on CXL) is listed as an acceptable treatment option for individuals age 13 years or older.

    Notification that Photrexa® products are expected to be withdrawn from the market effective January 20, 2026.

    2Medically appropriate indications

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    13+
    Min age for Epioxa™
    Photrexa®, Epioxa™FDA‑approved products referenced
    Do Not Implement Until 6/30/26Implementation hold date

    Coverage Criteria for Corneal Collagen Cross-Linking (CXL)

    Medical Appropriateness

    Corneal collagen cross-linking is considered medically appropriate when ALL of the following are met:

    Overall: All of the following must be met
    Indication: Treatment is indicated for ANY ONE of the following: progressive keratoconus; corneal ectasia after refractive surgery
    Conservative treatment: Failure of conservative treatment (e.g., spectacle correction, rigid contact lens) has occurred
    Product/Technique: Treatment performed with ANY ONE of the following acceptable products/techniques: Photrexa®; Epioxa™ for individuals age 13 years or older

    Photrexa products are noted as expected to be withdrawn effective Jan 20, 2026

    Corneal collagen cross-linking (CXL) for indications other than progressive keratoconus or corneal ectasia after refractive surgery is outside the scope of coverage in this policy and is considered investigational. Requests for CXL to treat other ocular conditions or diseases not listed in the medical appropriateness criteria are not supported.

    Any use of CXL that does not meet the stated medical appropriateness criteria in this policy is considered investigational and is not covered. Providers should ensure that all criteria (indication, documentation of failure of conservative treatment, and use of an acceptable product/technique) are met before submitting requests for coverage.

    Coding and Product References

    Referenced FDA-approved ophthalmic riboflavin productsmixed
    Photrexa®Riboflavin 5'-phospate ophthalmic solutions (Photrexa and Photrexa Viscous) — FDA approved for use with KXL System in corneal collagen cross-linking; Photrexa products expected to be withdrawn from the market effective January 20, 2026 with manufacturing ending in February 2026.
    Epioxa™Riboflavin 5'-phosphate ophthalmic solution (Epioxa and Epioxa HD) — FDA approved (2025) for treatment of keratoconus in adults and children aged 13 years and older; uses the O2n System and Boost Googles for epithelium-on corneal collagen cross-linking technology.
    Minimum age for Epioxa™
    Minimum age for Epioxa™>= 13 years
    Product indicationEpioxa™ approved for treatment of keratoconus in adults and children aged 13 years and older
    Associated systemEpioxa uses the O2n System™ and Boost Googles® for its epithelium-on technique

    Provider Requirements and Operational Notes

    Prior Authorization

    Prior authorization required when coverage depends on meeting criteria

    When coverage is contingent on meeting the medical appropriateness criteria for corneal collagen cross-linking (CXL) — including indication, failure of conservative therapy, and use of an acceptable product/technique — prior authorization must be obtained before performing CXL.

    Step Therapy

    Conservative treatment trial and failure required

    A documented trial and failure of conservative treatment (for example, spectacle correction or rigid contact lens) is required before CXL is considered medically appropriate.

    • Conservative treatments cited by the policy include spectacle correction and rigid contact lenses.

    Background

    Keratoconus is a progressive corneal disorder characterized by thinning and steepening of the cornea that can lead to irregular astigmatism and visual impairment; corneal ectasia after refractive surgery presents with a similar pattern of progressive corneal deformation following procedures such as LASIK. Corneal collagen cross-linking (CXL) is a photochemical procedure that uses riboflavin and ultraviolet A light to induce cross-links within the corneal stroma to stiffen the cornea and halt progression. CXL techniques include epithelium-off (epi-off), which removes central epithelium to allow direct stromal riboflavin penetration, and epithelium-on (epi-on/transepithelial), which preserves the epithelium and utilizes longer riboflavin loading or proprietary delivery systems.

    Definitions of Techniques

    Epithelium-off (epi-off) — definition
    Technique nameEpithelium-off (epi-off)
    Procedure descriptionApproximately 8 mm of central corneal epithelium is removed under topical anesthesia to allow riboflavin penetration into the stroma prior to UVA irradiation
    Riboflavin applicationRiboflavin solution applied every 1–3 minutes for ~30 minutes until stroma is penetrated
    Therapeutic goalRemoval permits direct stromal saturation to enable effective cross-linking with UVA-generated reactive oxygen species
    Epithelium-on (epi-on / transepithelial) — definition
    Technique nameEpithelium-on (epi-on / transepithelial)
    Policy Summary
    PayerBlue Cross Blue Shield - Tennessee
    PolicyCorneal collagen cross-linking (CXL) — Coverage Criteria
    Policy CodePolicy N/A
    Change TypeMaterial update — added Epioxa™ as acceptable optionPhotrexa® market withdrawal noted
    Effective DateN/A
    Last ReviewJun 30, 2026
    Next Review DateN/A
    Key ActionObtain prior authorization and document indication, prior conservative treatment failure, and the specific CXL product/technique used.
    SourceLink
    On This Page
    Coverage Criteria for Corneal Collagen Cross-Linking (CXL)Coding and Product ReferencesProvider Requirements and Operational NotesBackgroundDefinitions of Techniques
    Documentation Required

    Document indication, prior conservative treatments, and product/technique

    Provide documentation of the indication (progressive keratoconus or corneal ectasia after refractive surgery), the prior conservative treatments tried and their failure, and the specific CXL product or technique used (e.g., Photrexa products or Epioxa for individuals age 13 years or older).

    • Indication: progressive keratoconus or corneal ectasia after refractive surgery.
    • Conservative therapies attempted (e.g., spectacles, rigid contact lens) and evidence of failure.
    • Specific product/technique used (examples: Photrexa products; Epioxa with O2n System for ages ≥13).
    Denial Risk

    Denial risk if appropriateness criteria are not met

    Requests that do not meet all elements of the medical appropriateness criteria — indication, documented failure of conservative treatment, and use of an acceptable product/technique — may be denied.

    • Use of CXL for indications other than progressive keratoconus or post‑refractive corneal ectasia is considered investigational and may be denied.
    • If an acceptable product/technique is not demonstrated (including age requirements for Epioxa), coverage may be denied.
    Procedure descriptionEpithelium is left intact or partially disrupted; longer riboflavin loading time is required compared with epi-off
    Proprietary systemsIncludes proprietary systems such as Epioxa™ with the O2n System™ and Boost Googles® for epithelium-on CXL