CORNEAL SURGERY (FORMERLY CORNEAL TRANSPLANT, ENDOTHELIAL KERATOPLASTY AND KERATOPROSTHESES)
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Clinical coverage criteria and coding guidance for corneal transplantation, endothelial keratoplasty techniques, keratoprostheses, and other corneal surgeries for members of Capital BlueCross products (with product-specific variations noted).
Policy now includes criteria for other corneal surgery previously on MP 1.044 and corresponding codes were added.
Removed outdated ICD10 diagnosis codes H18.51, H18.52, H18.53, H18.54, H18.55, H18.59, T86.840, T86.841, T86.842, T86.848 and T86.849.
Updated background and references, including addition of recent Preferred Practice Pattern and literature on keratoprosthesis outcomes and complications.
Coverage Criteria
Corneal transplant indications
Covered when diagnosis is one of the following conditions:
Endothelial keratoplasty
Endothelial keratoplasty is considered medically necessary when ALL of the following apply:
Boston Keratoprosthesis (Boston KPro) criteria
Boston Keratoprosthesis (Boston KPro) may be considered medically necessary when ALL of the following are met:
See policy text for requirement that implantation be limited to experienced centers and consideration of contralateral eye vision and likelihood of benefit.
Other corneal surgery
Other corneal surgeries considered medically necessary when indicated:
Evidence-based coverage summaries
Summarized coverage stance based on evidence sections in this document segment
Sufficient evidence supports net health benefit for standard endothelial keratoplasty techniques.
Insufficient evidence for superiority or consistent benefit.
Evidence considered sufficient to determine improvement in net health outcome with careful patient selection.
Insufficient evidence to determine net health benefit.
Evidence insufficient to determine net health benefit.
Corneal Transplant - Covered Procedures
Covered when medically necessary for Corneal Transplant:
Endothelial Keratoplasty - Covered Procedures
Covered when medically necessary for Endothelial Keratoplasty:
Investigational / Not Covered Procedures
Not covered (Investigational):
Diagnoses Supporting Medical Necessity
Medically necessary diagnoses supporting coverage:
See policy chunks 43–55 and 58 for the full enumerated diagnosis codes.
Medical necessity by diagnosis code
Covered when medically necessary for indicated diagnoses
Diagnosis codes enumerated in chunks 54, 55, and 58 define medical necessity for the respective procedures.
Corneal transplantation for indications not listed in this policy (for example, purely refractive procedures such as correction of astigmatism or other refractive error) is considered investigational because there is insufficient evidence to conclude these procedures improve net health outcomes. In addition, femtosecond laser–assisted endothelial keratoplasty (FLEK/FELEK) is considered investigational; the evidence does not consistently demonstrate superior visual outcomes or reduced adverse events compared with standard techniques.
The evidence for alternative keratoprosthesis devices is limited. For the AlphaCor device, only small case series are available and reported complications (including anterior corneal thinning, melting, and necrosis) raise concerns; evidence is insufficient to determine net health benefit. For the osteo-odonto-keratoprosthesis, case series and a systematic review report high anatomic survival at 5 and 20 years, but visual outcomes are poorly described and the procedure is complex with substantial complication risk; available evidence is insufficient to establish improved net health outcomes.
The following CPT procedure codes are designated investigational and not covered: 65760, 65765, and 65771.
During the 04/27/2023 policy review a set of outdated ICD‑10 diagnosis codes were removed from the policy. These codes should no longer be used when documenting medical necessity or submitting claims for corneal procedures.
Endothelial keratoplasty is considered investigational when endothelial dysfunction is not the primary cause of decreased corneal clarity; available evidence does not support routine use of endothelial keratoplasty for non‑endothelial causes of corneal opacity.
Evidence evaluating femtosecond‑assisted endothelial keratoplasty is conflicting. Randomized and comparative studies have reported inconsistent results for best‑corrected visual acuity and endothelial cell loss versus penetrating keratoplasty and other preparation methods; therefore the literature is considered insufficient to demonstrate a clear net health benefit for femtosecond‑assisted techniques.
Coding
Provider Action Summary
Provider action: Prior authorization and medical necessity verification are required before performing corneal transplant, endothelial keratoplasty, or keratoprosthesis procedures. Verify member benefits and coverage, obtain product-specific prior authorization where applicable, and confirm the selected procedure is appropriate for the diagnosis and sequencing of prior treatments.
- Obtain product-specific prior authorization when required.
- Confirm medical necessity and member eligibility before scheduling.
- Document prior treatments and reason for procedure selection (see required documentation below).
- If procedure is for keratoprosthesis, document why standard penetrating keratoplasty is unsuitable (e.g., severe dry eye, mucosal keratinization, obliterated fornices).
- For endothelial keratoplasty, ensure diagnosis codes support coverage; claims with unsupported diagnosis codes may be denied.
Denial risk from removed ICD-10 codes
Use updated code lists when submitting claims. Codes removed from the policy history may lead to claim denial if used.
- Do not submit claims using removed ICD-10 codes listed above; replacement/valid codes from the current ICD-10 set must be used.
- If a removed code appears on a claim, anticipate denial risk and correct coding prior to claim re-submission.
Required clinical documentation
Required clinical documentation must accompany prior authorization requests and claims to support medical necessity.
- Clinical exam findings and operative notes detailing corneal pathology.
- History of prior treatments and outcomes (e.g., failed penetrating keratoplasty, prior graft rejection, prior medical therapy).
- Diagnostic testing (e.g., corneal topography, pachymetry, endothelial cell counts when relevant).
- Rationale for procedure selection and sequencing (why keratoprosthesis or endothelial keratoplasty is chosen over alternative procedures).
- For keratoprosthesis requests, documentation that standard penetrating keratoplasty is unsuitable or contraindicated, and description of adnexal surface condition (lid function, tear film status, fornices).
Provider Actions & Requirements
Confirm product-specific prior authorization requirements
This policy applies only to certain Capital BlueCross programs and products; some products (for example, FEP PPO) follow a separate FEP Medical Policy Manual.
- Verify whether the member's product is administered under this policy or under a separate product-specific manual (e.g., FEP PPO).
Obtain prior authorization / contact payer as needed
Prior authorization may be required depending on the member's benefit program; contact Capital Blue Cross Provider Services for questions or to determine authorization requirements.
- Providers should contact Provider Services if uncertain whether prior authorization is required for the member's benefit program.
Verify medical necessity — codes do not equal coverage
Identification of a procedure or diagnosis code in the coding section does not guarantee coverage; services listed as 'Covered when Medically Necessary' require a medical necessity determination and are subject to member benefit terms.
- Verify medical necessity and benefit eligibility before claim submission; code listing alone does not denote coverage.
Prior authorization required for keratoprosthesis (L8609, 65770)
Prior authorization is indicated for keratoprosthesis procedures identified in the policy (including HCPCS L8609 and CPT 65770).
- Include documentation supporting the keratoprosthesis indication when requesting authorization.
Prior authorization applies to newly added corneal surgery codes
Prior authorization requirements apply to the additional corneal surgery procedure codes added in the policy update; these codes were added to the policy on 04/24/2025 and require authorization per policy.
Select procedure appropriately — do not replace PK with endothelial keratoplasty when anterior disease exists
Do not substitute endothelial keratoplasty for penetrating keratoplasty when significant anterior corneal disease is present; surgeon judgment and appropriate training should guide procedure selection.
- If concurrent anterior corneal dystrophies, anterior scars, or ectasia are present, consider penetrating keratoplasty instead of endothelial keratoplasty unless endothelial disease is the primary cause of vision loss.
- Ensure the surgeon is adequately trained and experienced in the selected keratoplasty technique.
Follow evidence-based sequencing for endothelial keratoplasty and keratoprosthesis
Evidence summaries note when endothelial keratoplasty or keratoprosthesis are appropriate—these procedures are considered for patients with endothelial disease or for those who have failed or are not candidates for standard corneal transplantation.
- Use the evidence-based indications in the policy (e.g., endothelial dysfunction for endothelial keratoplasty; failed/not candidate for transplant for Boston KPro) to support treatment sequencing decisions.
Include required clinical details (indication, acuity thresholds, absence of end‑stage disease)
Clinical documentation must support the indication, visual acuity thresholds for Boston KPro, absence of end-stage glaucoma or retinal detachment, prior graft failures when applicable, and surgeon/center experience.
- For Boston KPro, document best-corrected vision ≤20/400 in the affected eye and ≤20/40 in the contralateral eye and absence of end-stage glaucoma or retinal detachment.
- Document prior graft failures, expected postoperative compliance, and that the procedure will be performed at an experienced center.
Document medical necessity and verify eligibility
Ensure documentation supports medical necessity and the member's eligibility; the policy does not guarantee coverage or payment and claims are subject to benefit and eligibility verification.
- Maintain records demonstrating the medical rationale for the procedure and that the member was eligible on the date of service.
Verify eligibility and benefits before performing services
Verify member eligibility and benefit program terms prior to scheduling or billing; contact Provider Services or Member Services if there is uncertainty about coverage or authorization requirements.
- Eligibility and benefit verification should be performed for the date of service; do not assume coverage based solely on this policy.
Provide diagnosis code documentation to support medical necessity
Clinical documentation must include one of the enumerated ICD-10 diagnosis codes indicating corneal endothelial disease, graft failure/rejection, or severe corneal disease that supports medical necessity for the requested procedure.
- Include the specific ICD-10 code from the policy's diagnosis lists (e.g., H18.11, H18.331 for endothelial keratoplasty; H16.441, H17.11 for keratoprosthesis) on authorization requests and claims.
Restrict keratoprosthesis to experienced centers — document severity and surgeon experience
Keratoprosthesis implantation is high-risk and should be restricted to experienced centers and surgeons; include documentation of severe corneal opacity, prior graft failures or qualifying indication, and expected patient compliance to support appropriateness.
- Document severity (e.g., severely opaque and vascularized cornea), best-corrected visual acuity thresholds, lack of end-stage glaucoma or retinal detachment, and center/surgeon experience.
Coverage contingent on eligibility and medical necessity
Coverage and payment depend on the member's benefit program and a determination that the services are medically necessary and appropriate; the policy alone does not guarantee payment.
- Final claim adjudication is subject to contract terms, benefit limitations, and exclusions applicable to the member's plan.
Coverage conditional on benefits and claim adjudication
Coverage determination is conditional on member benefit information and final claim payment is subject to eligibility, benefit limits, and medical necessity determinations at claim processing.
- Do not assume payment until claim adjudication is complete and benefits/eligibility have been confirmed.
Denial risk if required ICD-10 codes for endothelial keratoplasty are missing
Claims for endothelial keratoplasty that do not include one of the policy-listed ICD-10 diagnosis codes supporting medical necessity may be denied.
- Ensure claims list an appropriate diagnosis code from the endothelial keratoplasty diagnosis set (e.g., H18.11, H18.331) to justify medical necessity.
Denial risk if keratoprosthesis diagnosis codes are not submitted
Claims for keratoprosthesis procedures without one of the specified keratoprosthesis diagnosis codes (such as deep corneal vascularization, central corneal opacity, cicatricial pemphigoid, Stevens-Johnson syndrome, or burns) may be denied.
- Include an applicable keratoprosthesis diagnosis code (e.g., H16.441, H17.11, L12.1, L51.1, T26.10XA) on authorization requests and claims.
Avoid removed/outdated ICD-10 codes — risk of denial
Claims using ICD-10 diagnosis codes removed in the 04/27/2023 update (H18.51, H18.52, H18.53, H18.54, H18.55, H18.59, T86.840, T86.841, T86.842, T86.848, T86.849) may be at risk for denial or require correction.
- Do not bill with the removed/outdated ICD-10 codes listed in the policy history; update claims to current valid diagnosis codes from the policy's lists.
Background
The cornea is the transparent anterior surface of the eye composed of multiple layers (epithelium, Bowman's layer, stroma, Descemet membrane, and endothelium). Dysfunction of the corneal endothelium (for example, Fuchs endothelial dystrophy, bullous keratopathy, or graft failure) leads to stromal and epithelial edema and loss of transparency. Full‑thickness penetrating keratoplasty replaces all corneal layers but is associated with longer recovery and higher complication rates; by contrast, endothelial keratoplasty selectively replaces the diseased endothelium and Descemet membrane (techniques include DSEK/DSAEK and DMEK) and generally provides faster visual recovery and lower rates of some complications.
Case series and systematic reviews describe outcomes and complications for keratoprostheses. The Boston Keratoprosthesis (Boston KPro) has substantial published series and systematic reviews demonstrating improved visual outcomes in many patients who have failed or are not candidates for standard transplant, but it remains a high‑risk procedure with frequent complications and need for additional surgery. In contrast, evidence for the AlphaCor device is limited to a few series and reports of serious anterior corneal complications; osteo‑odonto‑keratoprosthesis series report long‑term anatomic survival but limited data on vision outcomes. These limitations inform the policy’s differentiated coverage stance across keratoprosthesis types.
Definitions
Revision History
Policy revised to include criteria for additional corneal surgeries and nine procedure codes were added (65760, 65765, 65771, 65400, 65767, 65772, 65781, 65782, S0810).
Consensus review with updates to references; no change to policy stance.
Consensus review removed outdated ICD-10 diagnosis codes (H18.51, H18.52, H18.53, H18.54, H18.55, H18.59, T86.840, T86.841, T86.842, T86.848, T86.849).
Administrative update removed Benefit Variations section and updated the disclaimer (administrative only).
Policy history notes that outdated ICD‑10 diagnosis codes were removed in the 04/27/2023 review. Providers should be aware that claims using those removed codes may be at risk for denial and should reference the current diagnosis code set when documenting medical necessity.
The policy was operationally updated to expand the list of covered corneal procedures and associated criteria; corresponding procedure codes were added on the 04/24/2025 update. Providers should reference the updated coding table in the policy and follow prior authorization requirements as applicable.
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