Surgical Choice Guidance: Endothelial Keratoplasty

Endothelial keratoplasty should not be substituted for penetrating keratoplasty when significant anterior corneal disease is present. Document the surgical rationale if endothelial keratoplasty is chosen in cases with concurrent anterior corneal pathology.

• Do not replace penetrating keratoplasty when anterior corneal dystrophies, anterior scars, or ectasia affecting the anterior cornea are present unless clinical documentation explains why endothelial disease is the primary cause of vision loss.
• Surgeons performing endothelial keratoplasty should be adequately trained and document technique and device expertise.

High-Risk Procedure — Risk and Site Requirements

Keratoprosthesis procedures are high-risk and associated with numerous potential complications and likely need for additional surgeries. Coverage decisions should weigh the likelihood of visual benefit, the condition of the contralateral eye, and availability of experienced surgical centers.

• Highlight the high complication rate (e.g., retroprosthetic membrane formation, infection, corneal melting) when submitting requests.
• Restrict treatment to centers experienced in keratoprosthesis care and staffed by appropriately trained surgeons.
• Consider the patient's overall prognosis and expected visual benefit prior to approval.

Investigational Procedures and Exclusions

Certain procedures and devices remain investigational and are not covered. Documentation that cites investigational devices or techniques will not alone establish coverage.

• Permanent keratoprostheses other than the Boston KPro (e.g., FLEK/FELEK or other investigational devices) are considered investigational and not covered.
• AlphaCor device outcomes are insufficient to establish net health benefit in all settings; coverage is limited per clinical evidence and may be reviewed case-by-case.
• If a requested device or procedure is investigational, do not assume coverage even if codes exist for billing.

Coding, Coverage, and Claims Processing

Coding and coverage are determined by member benefit terms. The code list in the policy is not exhaustive and may change. Use current codes and ensure submitted documentation aligns with the policy criteria to avoid denials.

• The presence of a code in this policy does not guarantee coverage; verify the member's benefit plan.
• This policy was expanded to include additional codes (e.g., 65760, 65765, 65771, 65400, 65767, 65782, S0810); prior authorization is required for these migrated codes.
• Providers must use current CPT/HCPCS/ICD-10 codes and update claim submissions per payer guidance; failure to do so may result in denial or processing delays.

Coverage Contingent on Member Benefits and Medical Necessity

Final coverage determination is contingent on the member's benefit program, eligibility on the date of service, and a medical necessity review. These policies do not guarantee payment.

• Payment is subject to verification of eligibility, benefit limitations, and exclusions in the member's contract.
• If there are questions regarding coverage or prior authorization requirements, contact Capital Blue Cross Provider Services or Member Services.

Operational Note: Documentation and Coding

Providers should include up-to-date operative and clinical documentation and select appropriate codes consistent with the current policy when submitting prior authorization requests and claims.

• Document the indication consistent with policy criteria, prior graft failures, prior treatments, and anticipated postoperative care needs.
• Use the most current procedure and diagnosis codes; the policy history shows code removals and additions—verify codes before submission.
• Failure to provide required documentation or to use current codes may affect coverage and reimbursement.