Corneal Collagen Cross-Linking
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Covers the medical necessity and investigational use of riboflavin-plus-UVA corneal collagen cross-linking for progressive keratoconus and corneal ectasia after refractive surgery for members of Capital Blue Cross programs; includes background, definitions, coding guidance, and references.
Title changed to Corneal Collagen Cross-Linking and multiple prior criteria (Corneal Pachymetry, Corneal Endothelial Microscopy and Transciliary Fistulization) were removed.
Removed codes 66999, 76514, 92286 and an extensive list of ICD-10 codes (H17.*, H18.*, H40.*, etc.).
Administrative update removed Benefit Variations Section and updated the Disclaimer.
Coverage Criteria
COVERAGE CRITERIA
Covered when ALL of the following are met
Primary covered indications
- Evidence of progression: One or more of: increase of 1 D in steepest keratometry; increase of 1 D in regular astigmatism; myopic shift (decrease in spherical equivalent) of 0.50 D; decrease ≥0.1 mm in back optical zone radiussee progression thresholds
Derived from FDA trial definitions and policy guidelines
- Prior conservative therapy: Failed conservative treatment such as spectacle correction or rigid contact lens use
Procedure is intended for individuals who have failed conservative treatment
Epithelium-on (transepithelial) techniques are considered investigational and not covered
Policy changes and removed criteria
Policy was materially revised; prior specific diagnostic/measurement criteria were removed during the major review.
These criteria no longer appear in the policy after the 06/18/2025 major review.
Corneal collagen cross-linking (CXL) using riboflavin and ultraviolet A is covered only for progressive keratoconus or corneal ectasia after refractive surgery when conservative therapy (for example, spectacle correction or rigid contact lens use) has failed. The policy explicitly states that CXL is investigational for all other indications due to insufficient evidence to conclude benefit.
The document also notes that the FDA-approved technique is the epithelium-off (epi-off) method and that epithelium-on (epi-on) or transepithelial techniques are not FDA-approved and therefore considered investigational for other indications.
A major policy review on 06/18/2025 revised the document title to Corneal Collagen Cross-Linking and removed multiple prior clinical criteria (including Corneal Pachymetry, Corneal Endothelial Microscopy, and Transciliary Fistulization). The same update also removed a number of diagnosis and procedure codes from the policy coding tables.
The policy history section documents those removals but does not, in this segment, replace them with a new long list of alternate exclusions; providers should refer to the updated coding tables and the current policy text for the active, supported codes and criteria.
Use of corneal collagen cross-linking for indications other than progressive keratoconus or corneal ectasia after refractive surgery is described as investigational and not supported as medically necessary. This includes epithelium-on (epi-on or transepithelial) CXL techniques, which are not FDA-approved according to the policy.
The policy rationale explains the mechanism (riboflavin plus UVA forming cross-links that stiffen the cornea) and reiterates that available FDA approval and trial evidence support CXL for stabilization in progressive keratoconus and post-refractive ectasia, but not for other disease states or unapproved procedural variants.
The provided policy segment does not enumerate explicit 'not medically necessary' conditions beyond stating that non‑approved indications are investigational. Instead, the 06/18/2025 major review is documented as having removed several diagnostic and procedural criteria and an extensive list of previously included diagnosis/procedure codes.
Because those criteria and codes were removed, the policy no longer lists them here; providers should follow the revised policy text and current coding tables when determining medical necessity or submitting authorizations and claims.
Coding
| H18.601 | Keratoconus, unspecified, right eye |
| H18.602 | Keratoconus, unspecified, left eye |
| H18.603 | Keratoconus, unspecified, bilateral |
| H18.609 | Keratoconus, unspecified, unspecified eye |
| H18.611 | Keratoconus, stable, right eye |
| H18.612 | Keratoconus, stable, left eye |
| H18.613 | Keratoconus, stable, bilateral |
| H18.619 | Keratoconus, stable, unspecified eye |
| H18.621 | Keratoconus, unstable, right eye |
| H18.622 | Keratoconus, unstable, left eye |
| H18.601 | Keratoconus, unspecified, right eye |
| H18.602 | Keratoconus, unspecified, left eye |
| H18.603 | Keratoconus, unspecified, bilateral |
| H18.609 | Keratoconus, unspecified, unspecified eye |
| H18.611 | Keratoconus, stable, right eye |
| H18.612 | Keratoconus, stable, left eye |
| H18.613 | Keratoconus, stable, bilateral |
| H18.619 | Keratoconus, stable, unspecified eye |
| H18.621 | Keratoconus, unstable, right eye |
| H18.622 | Keratoconus, unstable, left eye |
| 66999 | Unlisted procedure, anterior segment (removed from policy coding list) |
| 76514 | Ultrasonic pachymetry (removed from policy coding list) |
| 92286 | Corneal topography (removed from policy coding list) |
| H17.11 | Other corneal scars and opacities (removed from policy coding list) |
| H18.011 | Bullous keratopathy, right eye (removed from policy coding list) |
| H40.811 | Primary open-angle glaucoma suspect (example from long removed list) |
| H44.511 | Hypermetropia, right eye (example from removed list) |
| Z01.818 | Encounter for other preprocedural examinations (example from removed list) |
Provider Actions and Requirements
Prior Authorization Required
Prior authorization is required for corneal collagen cross-linking per product and program variations. Use the appropriate procedure and HCPCS codes when requesting prior authorization and consult member benefit information to confirm eligibility and coverage.
Conservative Therapy Required Before Cross‑Linking
Conservative therapy should be attempted and documented prior to performing corneal collagen cross-linking. Examples of conservative treatments include spectacle correction and rigid (gas permeable) contact lens use.
- Document trial and failure or intolerance of conservative measures (e.g., spectacle correction, rigid contact lens) before proceeding with cross-linking.
Coding Removals May Trigger Denial
Claims or authorization requests that include codes removed from the policy coding tables may be at risk for denial or miscoding. Providers should update billing to reflect the current coding table and remove deprecated codes from submissions.
Background
Keratoconus is a progressive corneal disorder characterized by stromal thinning and anterior corneal steepening that can lead to irregular astigmatism and visual impairment. Corneal ectasia refers to a similar progressive thinning and deformation of the cornea occurring after refractive surgery.
Corneal collagen cross-linking (CXL) is a photochemical procedure that combines topical riboflavin with ultraviolet A light to induce additional covalent bonds between collagen molecules, increasing corneal biomechanical strength and aiming to slow or halt progression. The policy highlights that FDA approval exists for the epithelium-off (epi-off) CXL technique, with epi-on approaches currently not FDA-approved and considered investigational.
Definitions
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