CurrentCapital BluecrossPolicy MP 9.011

Corneal Surgery, Implantation of Intrastromal Corneal Ring Segment, and Corneal Topography Photokeratoscopy

Capital BlueCross medical policy MP 9.011 defines medical necessity criteria, investigational exclusions, and coding guidance for corneal transplantation (including penetrating and lamellar keratoplasty), endothelial keratoplasty (DSEK/DSAEK/DMEK/DMAEK), keratoprostheses (Boston KPro, AlphaCor, osteo-odonto), and other corneal surgical procedures and refractive keratoplasties. It also provides product variation notes and lists procedure and diagnosis codes associated with coverage and investigational status.

Policy Summary

PayerCapital Bluecross

PolicyCorneal Surgery, Implantation of Intrastromal Corneal Ring Segment, and Corneal Topography Photokeratoscopy

Policy CodePolicy MP 9.011

Change TypeMinor ReviewAdministrative UpdateConsensus Reviews

Effective Date10/1/2025

Next Review Date

Key ActionDocument severe corneal opacity and vascularization, best-corrected visual acuity in both eyes (≤20/400 affected, ≤20/40 contralateral), absence of end-stage glaucoma or retinal detachment, indication basis (one of listed indications), patient ability to comply with postoperative care, and center/surgeon experience.

SourceLink

POLICY UPDATE CHANGES

04/24/2025 Minor Review: Policy now includes criteria for other corneal surgery previously on 1.044; corresponding codes added (65760, 65765, 65771, 65400, 65767, 65772, 65781, 65782, S0810).

05/17/2024 Consensus Review: No change to policy stance. Updated references.

04/27/2023 Consensus Review: No change to policy statement. Rationale and References updated. Removed outdated ICD10 codes H18.51, H18.52, H18.53, H18.54, H18.55, H18.59, T86.840, T86.841, T86.842, T86.848 and T86.849.

08/13/2025 Administrative Update: Removed Benefit Variations Section and updated Disclaimer.

3Procedures investigational (examples)

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 Summary

Capital BlueCross medical policy MP 9.011 (Effective date: 10/1/2025) defines coverage and investigational exclusions for corneal surgery. The policy takes a mixed coverage stance: it specifies medically necessary indications and coding guidance for traditional corneal transplantation (penetrating keratoplasty and lamellar keratoplasty), for posterior lamellar or endothelial keratoplasty (DSEK/DSAEK/DMEK/DMAEK), and for keratoprostheses (including the Boston Keratoprosthesis). It also incorporates criteria and added procedure codes for other corneal surgery (e.g., procedures moved from policy 1.044).

Key policy facts

Policy NumberMP 9.011

Effective Date10/1/2025

Coverage Stancemixed

Example covered CPT/Procedure codes (count)8 (e.g., 65400, 65767, 65772, 65775, 65781, 65782, S0810, additional covered groups)

Investigational procedure codes (count)3 (65760, 65765, 65771)

ICD-10 codes listed (approx.)100+ (multiple diagnosis codes for corneal disease, transplant complications, keratoprosthesis indications)

SubjectCorneal surgery, corneal transplant, endothelial keratoplasty, keratoprostheses

Medical Necessity Criteria

Corneal Transplant - Medically Necessary Indications

Corneal transplantation may be considered medically necessary for individuals with the following conditions:

ANY of the following

Aphakic corneal edema
Chemical injuries
Complications of transplanted organ
Congenital opacities
Corneal degenerations

Coding

Investigational, and therefore not covered - Procedure CodesCPTNot Covered

65760
65765
65771

Covered when Medically Necessary - Procedure CodesCPTCovered

65400
65767
65772
65775
65781
65782
S0810

Covered when Medically Necessary for Corneal Transplant - Procedure Codes (listed fragmentarily)CPTCovered

65710
65730
65750
65755

Covered when Medically Necessary for Endothelial Keratoplasty - Procedure CodesCPTCovered

65756
65757

Medically Necessary Diagnosis Codes for Corneal Transplant (ICD-10)ICD-10Covered

A18.52	Tuberculous keratitis
A18.59	Other tuberculosis of eye
A54.33	Gonococcal keratitis
B00.52	Herpesviral keratitis
B02.33	Zoster keratitis
B05.81	Measles keratitis and keratoconjunctivitis
B30.0	Keratoconjunctivitis due to adenovirus
B60.13	Keratoconjunctivitis due to Acanthamoeba
H16.011	Central corneal ulcer, right eye
H16.012	Central corneal ulcer, left eye

1–10 of 129

1/13

Covered Procedure Codes - Endothelial KeratoplastyCPTCovered

65756	Procedure code listed as covered for endothelial keratoplasty
65757	Procedure code listed as covered for endothelial keratoplasty

Covered Procedure/Device Codes - KeratoprosthesesmixedCovered

C1818	HCPCS product/code referenced for keratoprosthesis
L8609	L-code listed in keratoprosthesis section
65770	Procedure code listed for keratoprostheses

Additional Corneal Surgery Procedure Codes AddedCPT|HCPCSCovered

65760	Added to policy for other corneal surgery
65765	Added to policy for other corneal surgery
65771	Added to policy for other corneal surgery
65400	Added to policy for other corneal surgery
65767	Added to policy for other corneal surgery
65772	Added to policy for other corneal surgery
65781	Added to policy for other corneal surgery
65782	Added to policy for other corneal surgery
S0810	Added to policy for other corneal surgery

Diagnosis Codes (ICD-10) - Corneal transplant complications/status and other corneal diagnosesICD-10

H18.11	Bullous keratopathy, right eye
H18.12	Bullous keratopathy, left eye
H18.13	Bullous keratopathy, bilateral
H18.331	Rupture in Descemet's membrane, right eye
H18.332	Rupture in Descemet's membrane, left eye
H18.333	Rupture in Descemet's membrane, bilateral
H18.51	Endothelial corneal dystrophy
H18.52	Epithelial (juvenile) corneal dystrophy
H18.53	Granular corneal dystrophy
H18.54	Lattice corneal dystrophy

1–10 of 58

1/6

Provider Actions / Documentation Requirements

Documentation Required

KPro patient selection and documentation

Document severe corneal opacity and deep vascularization; best-corrected visual acuity in both eyes (affected eye ≤20/400; contralateral eye ≤20/40); absence of end-stage glaucoma or retinal detachment; the specific indication from the policy list (e.g., prior graft failures, Stevens‑Johnson syndrome, ocular cicatricial pemphigoid, autoimmune conditions with ocular involvement, ocular chemical burns, or an ocular condition unlikely to respond to primary corneal transplant such as limbal stem cell compromise or post‑herpetic anesthesia); that the patient is expected to be compliant with postoperative care; and that treatment will be performed at a center experienced with keratoprosthesis implantation and by surgeons trained in these techniques.

Affected eye BCVA documented as ≤20/400
Contralateral eye BCVA documented as ≤20/40
Document corneal severe opacity and vascularization
Confirm no end-stage glaucoma or retinal detachment
Specify the ONE listed indication supporting KPro
Document patient ability to comply with postoperative care
Document center and surgeon experience with KPro implantation

Background, Evidence, and Definitions

The cornea is a clear, dome-shaped membrane covering the front of the eye; its layers include the epithelium, Bowman layer, the stroma (≈90% of corneal thickness), Descemet membrane, and the endothelium. The endothelium maintains corneal clarity by removing and limiting fluid in the stroma; endothelial dysfunction (for example, Fuchs endothelial dystrophy, aphakic or pseudophakic bullous keratopathy, or failure/rejection of a prior graft) leads to corneal edema and loss of transparency.

Traditional penetrating keratoplasty (PK) replaces full-thickness donor cornea and may require prolonged visual rehabilitation and carries risks such as irregular astigmatism from sutures, wound dehiscence, endophthalmitis, expulsive suprachoroidal hemorrhage, and catastrophic wound failure. Posterior lamellar approaches—collectively called endothelial keratoplasty (EK)—selectively replace the diseased endothelium and Descemet membrane. Techniques include DSEK, DSAEK, DMEK, and DMAEK, with donor tissue prepared by hand, microkeratome, or laser. EK is associated with faster visual recovery (typically 4–8 weeks), less postoperative astigmatism, and avoidance of full‑thickness wound complications, but has procedure-specific risks such as graft dislocation, endothelial cell loss, increased intraocular pressure, graft rejection, and late endothelial failure and may require repositioning in the early postoperative period.

Endothelial keratoplasty is considered standard for many endothelial disorders; however, laser-assisted variations (femtosecond or femtosecond/excimer assisted EK) are considered investigational in this policy. As a surgical procedure, EK itself is not FDA-regulated, although microkeratomes used in donor preparation have received FDA 510(k) clearance.

Keratoprostheses are artificial corneas intended for patients with severe corneal opacity who are poor candidates for standard transplant. The Boston (Dohlman‑Doane) Keratoprosthesis (Boston KPro) has FDA premarket approval (1992) for use when standard corneal transplant has failed or is unlikely to succeed; case series and systematic reviews show improved visual outcomes but high complication rates and the need for careful patient selection and experienced centers. The AlphaCor device was cleared via 510(k) (August 2002) and has been associated with limited evidence of benefit and notable complications (anterior surface thinning/melting and necrosis).

Revision History

04/24/2025revised

Minor Review (material): Updated background and references; policy now includes criteria for other corneal surgery previously on 1.044 and corresponding codes added (65760, 65765, 65771, 65400, 65767, 65772, 65781, 65782, S0810).

05/17/2024clarified

Consensus Review: No change to policy stance; updated references.

04/27/2023revised

Consensus Review: No change to policy statement; rationale and references updated; removed outdated ICD-10 codes H18.51, H18.52, H18.53, H18.54, H18.55, H18.59, T86.840, T86.841, T86.842, T86.848 and T86.849.

Policy Summary

PayerCapital Bluecross

PolicyCorneal Surgery, Implantation of Intrastromal Corneal Ring Segment, and Corneal Topography Photokeratoscopy

Policy CodePolicy MP 9.011

Change TypeMinor ReviewAdministrative UpdateConsensus Reviews

Effective Date10/1/2025

Next Review Date

SourceLink

On This Page

Keratoprosthesis (Boston KPro) - Medically Necessary Criteria

The Boston (Dohlman-Doane) Keratoprosthesis may be considered medically necessary when ALL of the following are met:

ALL of the following

The cornea is severely opaque and vascularized
Best-corrected vision is ≤20/400 in the affected eye and ≤20/40 in the contralateral eye
No end-stage glaucoma or retinal detachment is present
ONE of the following indications
- History of 1 or more corneal transplant graft failures
- Stevens-Johnson syndrome
- Ocular cicatricial pemphigoid
- Autoimmune conditions with rare ocular involvement
- Ocular chemical burns
- An ocular condition unlikely to respond favorably to primary corneal transplant surgery (e.g., limbal stem cell compromise or post herpetic anesthesia)
Patient should be expected to be able to be compliant with postoperative care
Treatment should be restricted to centers experienced in treating this condition and staffed by surgeons adequately trained in implantation of this device

Investigational branch: A permanent keratoprosthesis for all other conditions is considered investigational. All other types of permanent keratoprostheses are considered investigational.

Endothelial Keratoplasty - Medically Necessary Indications

Endothelial keratoplasty (DSEK/DSAEK/DMEK/DMAEK) may be considered medically necessary for treatment of endothelial dysfunction including, but not limited to:

ANY of the following

Ruptures in Descemet membrane
Endothelial dystrophy
Aphakic and pseudophakic bullous keratopathy
Iridocorneal endothelial syndrome
Corneal edema attributed to endothelial failure
Failure or rejection of a previous corneal transplant

Investigational: Endothelial keratoplasty is investigational when endothelial dysfunction is not the primary cause of decreased corneal clarity. Femtosecond laser-assisted endothelial keratoplasty (FLEK) or femtosecond and excimer laser-assisted endothelial keratoplasty (FELEK) are considered investigational.

Guidance/Limitations: Endothelial keratoplasty should not be used in place of penetrating keratoplasty for conditions with concurrent endothelial disease and anterior corneal disease unless endothelial disease is the primary cause of decreased vision. Endothelial keratoplasty should be performed by surgeons who are adequately trained and experienced in the specific techniques and devices used.

Covered when Medically Necessary for Endothelial Keratoplasty

Covered when Medically Necessary for Endothelial Keratoplasty:

Procedure codes: 65756, 65757

These procedure codes are listed as covered for endothelial keratoplasty.

Diagnosis codes supporting medical necessity (ANY of the following ICD-10 codes)

H18.11 Bullous keratopathy, right eye
H18.12 Bullous keratopathy, left eye
H18.13 Bullous keratopathy, bilateral
H18.331 Rupture in Descemet's membrane, right eye
H18.332 Rupture in Descemet's membrane, left eye
H18.333 Rupture in Descemet's membrane, bilateral
H18.51 Endothelial corneal dystrophy
H18.52 Epithelial (juvenile) corneal dystrophy
H18.53 Granular corneal dystrophy
H18.54 Lattice corneal dystrophy
H18.55 Macular corneal dystrophy
H18.59 Other hereditary corneal dystrophies
H18.891 Other specified disorders of cornea, right eye
H18.892 Other specified disorders of cornea, left eye
H18.893 Other specified disorders of cornea, bilateral
H59.011 Keratopathy (bullous aphakic) following cataract surgery, right eye
H59.012 Keratopathy (bullous aphakic) following cataract surgery, left eye
H59.013 Keratopathy (bullous aphakic) following cataract surgery, bilateral
T85.398A Other mechanical complication of other ocular prosthetic devices, implants and grafts, initial encounter
T85.398D Other mechanical complication of other ocular prosthetic devices, implants and grafts, subsequent encounter
T86.840 Corneal transplant rejection
T86.8401 Corneal Transplant Rejection, Right Eye
T86.8402 Corneal Transplant Rejection, Left Eye
T86.8403 Corneal Transplant Rejection, Bilateral
T86.8409 Corneal Transplant Rejection, Unspecified Eye
T86.841 Corneal transplant failure
T86.8411 Corneal Transplant Failure, Right Eye
T86.8412 Corneal Transplant Failure, Left Eye
T86.8413 Corneal Transplant Failure, Bilateral
T86.8419 Corneal Transplant Failure, Unspecified Eye
T86.842 Corneal transplant infection
T86.8421 Corneal transplant infection, Right Eye
T86.8422 Corneal transplant infection, Left Eye
T86.8423 Corneal transplant infection, Bilateral
T86.8429 Corneal transplant infection, Unspecified Eye
T86.848 Other complications of corneal transplant
T86.8481 Other Complications of Corneal Transplant, Right Eye
T86.8482 Other Complications of Corneal Transplant, Left Eye
T86.8483 Other Complications of Corneal Transplant, Bilateral
T86.8489 Other Complications of Corneal Transplant, Unspecified Eye
T86.849 Unspecified complication of corneal transplant
T86.8491 Unspecified Complication of Corneal Transplant, Right Eye
T86.8492 Unspecified Complication of Corneal Transplant, Left Eye
T86.8493 Unspecified Complication of Corneal Transplant, Bilateral
T86.8499 Unspecified Complication of Corneal Transplant, Unspecified Eye
Z94.7 Corneal transplant status

Covered when Medically Necessary for Keratoprostheses

Covered when Medically Necessary for Keratoprostheses:

Procedure/HCPCS/L-code references listed as covered: C1818, L8609, 65770

C1818 appears repeatedly as a referenced code; 65770 listed as procedure for keratoprostheses.

Diagnosis codes supporting medical necessity (ANY of the following ICD-10 codes)

H16.441 Deep vascularization of cornea, right eye
H16.442 Deep vascularization of cornea, left eye
H16.443 Deep vascularization of cornea, bilateral
H16.449 Deep vascularization of cornea, unspecified eye
H17.10 Central corneal opacity, unspecified eye
H17.11 Central corneal opacity, right eye
H17.12 Central corneal opacity, left eye
H17.13 Central corneal opacity, bilateral
H17.89 Other corneal scars and opacities
L12.1 Cicatricial pemphigoid
L51.1 Stevens-Johnson syndrome
T26.10XA Burn of cornea and conjunctival sac, unspecified eye, initial encounter
T26.10XD Burn of cornea and conjunctival sac, unspecified eye, subsequent encounter
T26.11XA Burn of cornea and conjunctival sac, right eye, initial encounter
T26.11XD Burn of cornea and conjunctival sac, right eye, subsequent encounter
T26.12XA Burn of cornea and conjunctival sac, left eye, initial encounter
T26.12XD Burn of cornea and conjunctival sac, left eye, subsequent encounter
T86.8401 Corneal Transplant Rejection, Right Eye
T86.8402 Corneal Transplant Rejection, Left Eye
T86.8403 Corneal Transplant Rejection, Bilateral
T86.8409 Corneal Transplant Rejection, Unspecified Eye
T86.841 Corneal transplant failure
T86.8411 Corneal Transplant Failure, Right Eye
T86.8412 Corneal Transplant Failure, Left Eye
T86.8413 Corneal Transplant Failure, Bilateral
T86.8419 Corneal Transplant Failure, Unspecified Eye
T86.842 Corneal transplant infection
T86.8421 Corneal transplant infection, Right Eye
T86.8422 Corneal transplant infection, Left Eye
T86.8423 Corneal transplant infection, Bilateral
T86.8429 Corneal transplant infection, Unspecified Eye
T86.848 Other complications of corneal transplant
T86.8481 Other Complications of Corneal Transplant, Right Eye
T86.8482 Other Complications of Corneal Transplant, Left Eye
T86.8483 Other Complications of Corneal Transplant, Bilateral
T86.8489 Other Complications of Corneal Transplant, Unspecified Eye
T86.849 Unspecified complication of corneal transplant
T86.8491 Unspecified Complication of Corneal Transplant, Right Eye
T86.8492 Unspecified Complication of Corneal Transplant, Left Eye
T86.8493 Unspecified Complication of Corneal Transplant, Bilateral
T86.8499 Unspecified Complication of Corneal Transplant, Unspecified Eye
Z94.7 Corneal transplant status

Documentation Required

Endothelial keratoplasty surgical expertise

Document that the surgeon is adequately trained and experienced in the specific endothelial keratoplasty (EK) techniques and devices to be used. When choosing EK versus penetrating keratoplasty, document the primary cause of the decreased corneal clarity and confirm that endothelial dysfunction is the primary cause if EK is being considered (EK should not replace PK when significant anterior corneal disease is the primary contributor).

Documentation Required

Support diagnosis with listed ICD-10 codes

When billing for endothelial keratoplasty or keratoprosthesis procedures, include a supporting diagnosis from the policy's listed ICD‑10 codes. Use one of the diagnoses enumerated in the policy sections for Endothelial Keratoplasty or for Keratoprostheses as the medical-necessity diagnosis on the claim and in the medical record.

Use the policy's ICD‑10 diagnosis lists for EK (e.g., H18.11, H18.221, H18.331, H59.011, T86.x series, Z94.7) or for keratoprostheses (e.g., H16.441, H17.11, L12.1, L51.1, T26.x series) as appropriate

Study/Source	Key finding
DETECT RCT
Reported improved visual acuity with DMEK vs ultra-thin DSAEK
Eye Bank Association of America data
EK cases increased from 30,710 (2015) to 35,555 (2019); ~40% of corneal transplants in 2016 were endothelial grafts
Systematic review (Boston KPro)
2015 review included 22 series, 2176 eyes, showing improvement in visual outcomes but high complication rates
Cochrane review
DMEK vs DSAEK (Cochrane CD012097, 2018) cited
AAO report
American Academy of Ophthalmology reports and multiple randomized trials/meta-analyses cited (2019-2023)