ModifiedBlue Cross Complete of MichiganPolicy N/A

Laser-Assisted in Situ Keratomileusis and Radial Keratotomy (LASIK)

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This policy governs coverage, payment conditions, reimbursement, member cost sharing, and billing for LASIK and radial keratotomy under select Medicare Plus Blue Group PPO enhanced benefit plans. Original Medicare does not cover these procedures, so plan-specific benefit terms apply.

Policy Summary

PayerBlue Cross Complete of Michigan

PolicyLASIK and radial keratotomy enhanced benefits

Policy CodePolicy N/A

Change TypeModified

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionVerify enhanced-benefit eligibility under the member’s Medicare Plus Blue Group PPO plan before providing service.

SourceLink

POLICY UPDATE CHANGES

The policy was transitioned to a new template.

Coverage for an individual member was removed.

2Refractive procedures addressed

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ModifiedBlue Cross Complete of MichiganPolicy N/A

Laser-Assisted in Situ Keratomileusis and Radial Keratotomy (LASIK)

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Sign up for all blue_cross_complete_of_michigan policy alerts

Know when blue_cross_complete_of_michigan releases new policies or updates existing guidance.

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Policy Summary

PayerBlue Cross Complete of Michigan

PolicyLASIK and radial keratotomy enhanced benefits

Policy CodePolicy N/A

Change TypeModified

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionVerify enhanced-benefit eligibility under the member’s Medicare Plus Blue Group PPO plan before providing service.

SourceLink

POLICY UPDATE CHANGES

The policy was transitioned to a new template.

Coverage for an individual member was removed.

2Refractive procedures addressed

CPT/HCPCS codes listed

24ICD-10 codes listed

NoneFrequency and age restrictions

Lesser of allowed amount or chargeProvider reimbursement basis

100%Noncovered elected-service responsibility

Enhanced Benefit Coverage Criteria

Enhanced Benefit Eligibility and Payment

Coverage and payment for LASIK and radial keratotomy are available under the applicable enhanced benefit when the member is enrolled in an eligible plan and the payment conditions below are met.

ALL of the following

The procedure is LASIK to treat a refractive defect or radial keratotomy.
The member is enrolled in a Medicare Plus Blue Group PPO plan that includes coverage for LASIK and radial keratotomy.
Benefit scope, reimbursement methodology, maximum allowed payment amounts, and member cost sharing follow Blue Cross requirements for individual coverage or the applicable group requirements for group-based coverage.

Conditions for Payment

Payment is subject to all of the following conditions:

Eligible provider: M.D., D.O., ophthalmologist, or optometrist.
Payable location: No restrictions.
Frequency limits: No restrictions.
Diagnosis: No diagnosis requirement is specified.
Age restrictions: No restrictions.

LASIK procedures to treat refractive defects and radial keratotomy are not covered under Original Medicare.

LASIK and radial keratotomy are available only through the applicable enhanced benefit under select Medicare Plus Blue Group PPO plans, rather than as standard Original Medicare benefits.

Covered Procedure and Diagnosis Codes

Covered CPT/HCPCS CodesmixedCovered

S0800	Laser in situ keratomileusis (LASIK)
65771	Radial keratotomy
76514	Ophthalmic ultrasound, diagnostic; corneal pachymetry, unilateral or bilateral (determination of corneal thickness)
92025	Computerized corneal topography, unilateral or bilateral, with interpretation and report
92134	Computerized ophthalmic diagnostic imaging (e.g., optical coherence tomography [OCT]), posterior segment, with interpretation and report, unilateral or bilateral; retina

Covered ICD-10 CodesICD-10Covered

H52.00	Hypermetropia, unspecified eye
H52.01	Hypermetropia, right eye
H52.02	Hypermetropia, left eye
H52.03	Hypermetropia, bilateral
H52.10	Myopia, unspecified eye
H52.11	Myopia, right eye
H52.12	Myopia, left eye
H52.13	Myopia, bilateral
H52.201	Unspecified astigmatism, right eye
H52.202	Unspecified astigmatism, left eye

1–10 of 20

1/2

Verification, Billing, and Claims Guidance

Billing Rule

Claim Submission Requirements

Submit claims on the CMS-1500 (02/12), UB-04, or equivalent 837 claim form. Use Medicare Advantage PPO billing requirements, report CPT/HCPCS and diagnosis codes to the highest level of specificity, and include the National Provider Identifier (NPI) on every claim.

Accepted forms: CMS-1500 (02/12), UB-04, or the equivalent 837 claim form.
Use Medicare Advantage PPO unique billing requirements.
Report CPT/HCPCS and diagnosis codes to the highest level of specificity.
Report the billing provider's National Provider Identifier (NPI) on all claims.

Billing Rule

Verify the Maximum Payment Amount

Confirm the applicable Medicare Plus Blue maximum payment amount in Availity Essentials before submitting or pricing the claim. The provider is paid the lesser of the allowed amount or the provider's charge, minus the member's cost share; this is payment in full, and balance billing for the difference is not allowed.

Procedure Background

LASIK is a refractive keratoplasty procedure that permanently changes the shape of the cornea. A microkeratome creates a hinged corneal flap, and a computer-controlled laser removes stromal tissue before the flap is replaced. Radial keratotomy corrects myopia through precise radial microincisions in the cornea that flatten the central cornea and improve vision.

Key Terms

Laser-Assisted in Situ Keratomileusis (LASIK)

DefinitionA surgical procedure that permanently changes the shape of the cornea.

ProcedureA microkeratome cuts a hinged flap in the cornea, exposing the stroma.

Laser treatmentPulses from a computer-controlled laser vaporize part of the stroma, after which the flap is replaced.

Refractive keratoplasty

DefinitionA group of corneal surgical procedures intended to improve vision by changing the refractive index of the corneal surface.

ScopeLASIK is one of several surgical procedures included under the generic term refractive keratoplasty.

Policy Summary

PayerBlue Cross Complete of Michigan

PolicyLASIK and radial keratotomy enhanced benefits

Policy CodePolicy N/A

Change TypeModified

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionVerify enhanced-benefit eligibility under the member’s Medicare Plus Blue Group PPO plan before providing service.

SourceLink

On This Page

In Availity Essentials, open Secure Provider Resources and select the Medicare Plus Blue PPO Enhanced Benefit Fee Schedule under Fee Schedules.
Do not bill the member for the difference between the allowed amount and the provider's charge.

Note

Verify Benefits and Cost Sharing

Verify member benefits and applicable cost sharing through the provider portal or by calling 1-866-309-1719. When possible, collect only the appropriate Medicare Plus Blue copayment, coinsurance, or deductible at the time of service.

Cost sharing may be a flat-dollar copayment, percentage coinsurance, or deductible.
Collect only the member's applicable Medicare Plus Blue cost-sharing amount.

Billing Rule

Electronic and Paper Claim Routing

Send electronic and paper claims to the member's local Blue Cross plan. Michigan providers can use the Blue Cross EDI resources for ANSI ASC X12N 837 and 835 institutional and professional claim/payment transactions; providers outside Michigan should contact their local Blue Cross plan.

Michigan electronic billing resources: bcbsm.com/providers/help/edi/; see the EDI Institutional 837/835 Companion Documents in the reference library.
Michigan paper claims: Blue Cross Blue Shield of Michigan Imaging and Support Services, P.O. Box 32593, Detroit, MI 48232-0593.
Providers outside Michigan should contact their local Blue Cross plan for electronic and paper claim instructions.

Unsupported block type: documentation

Note

Verify Enhanced-Benefit Eligibility

Before furnishing LASIK or radial keratotomy, confirm that the member is enrolled in a Medicare Plus Blue Group PPO plan that includes the enhanced benefit. Verify the benefit scope, reimbursement methodology, maximum payment amount, and member cost sharing because these terms are determined by Blue Cross for individual coverage and by the group for group-based coverage.

Coverage is available only under select Medicare Plus Blue Group PPO plans.
Original Medicare does not cover LASIK or radial keratotomy; enhanced-benefit terms therefore control.

Unsupported block type: prior_auth

Denial Risk

Noncovered Elected Services

When a member elects a noncovered service, the member is responsible for the entire charge associated with that noncovered service, subject to applicable policy rules. Providers may not have the member sign an Advance Beneficiary Notice of Noncoverage to accept financial responsibility.

Obtain a coverage determination before providing any service whose coverage is uncertain.
If the provider supplies the noncovered item without a prior coverage determination, hold the member harmless for all charges except any applicable cost share.

Radial keratotomy

DefinitionA surgical correction for myopia (nearsightedness) using precise microincisions in the cornea.

Incision patternThe physician places usually eight or fewer radial microincisions on the corneal surface in a pattern resembling the spokes of a wheel.

EffectThe incisions allow the central cornea to flatten, reducing its convexity and improving vision.

Medicare Advantage Enhanced Benefit Policy

DefinitionPolicies that list the criteria BCBSM and BCN use to decide which medical services are considered reasonable and necessary when Medicare coverage rules are not fully developed.

Governing documentsIndividual member benefit plan documents, including the Evidence of Coverage and Annual Notice of Change, and applicable laws govern benefit coverage and related restrictions.

Policy statusThese policies are created when permitted by applicable laws, reviewed regularly, and may be revised periodically.