ModifiedCapital BluecrossPolicy MP 1.044

Implantation of Intrastromal Corneal Ring Segment

This policy governs coverage criteria for implantation of intrastromal corneal ring segments (ICRS) primarily for treatment of keratoconus and states investigational positions for other indications; it applies to Capital Blue Cross products as specified. Affected providers are ophthalmologists and surgical services evaluating members for ICRS implantation.

Policy Summary

PayerCapital Bluecross

PolicyImplantation of Intrastromal Corneal Ring Segment

Policy CodePolicy MP 1.044

Change TypeMajor reviewcoding and scope narrowed

Effective DateNov 1, 2025

Next Review Date

Key ActionObtain prior authorization for CPT 65785 and document age ≥21, progressive vision deterioration, clear central cornea, and corneal thickness ≥450 microns at the proposed incision site.

SourceLink

POLICY UPDATE CHANGES

Policy now only speaks to intrastromal corneal ring segments; corneal surgery and corneal topography codes moved to other policies.

Added ICD-10 codes H18.711-H18.719 and S05.00XA-S05.02XS to list of covered diagnoses.

Removed Benefit Variations Section and updated Disclaimer.

21+minimum patient age for covered keratoconus indication

>=450µmminimum corneal thickness

65785procedure code

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Coverage Criteria for Intrastromal Corneal Ring Segments (ICRS)

ICRS for keratoconus (medically necessary)

Covered when ALL of the following are met:

Keratoconus coverage criteria: Patient is 21 years of age or older.>= 21 years

Age requirement aligns with FDA HDE indication and policy statement.

Keratoconus coverage criteria: Patient has experienced progressive deterioration in vision such that they can no longer achieve adequate functional vision with contact lenses or spectacles.

Documentation should support progressive visual decline and inability to obtain adequate functional vision with conservative measures.

Keratoconus coverage criteria: Patient has a clear central cornea and corneal thickness of at least 450 microns at the proposed incision site.>= 450 microns at proposed incision site

Corneal clarity and minimum pachymetry required per policy and FDA HDE indication.

Investigational uses

Not covered / investigational for the following:

Investigational indications: Treatment of myopia.

Policy states Intacs for myopia is investigational due to insufficient evidence of net health benefit.

Investigational indications: All other conditions not meeting the keratoconus coverage criteria (including pellucid marginal degeneration and astigmatism after penetrating keratoplasty when criteria are not met).

Evidence for these indications is limited and insufficient to conclude improvement in net health outcome.

Coverage Criteria

Coverage Criteria: (See policy statement for the specific medical necessity criteria for keratoconus; policy history and references provide supporting evidence and context.)

References include multiple single-center case series and systematic reviews; policy history documents coding and scope changes.

Intrastromal corneal ring segments (ICRS) are considered investigational when used to treat myopia or for any condition that does not meet the specified keratoconus coverage criteria. The policy states there is insufficient evidence to support a general conclusion concerning health outcomes or benefits for these indications, and therefore ICRS for myopia and other non‑keratoconus conditions are not covered.

The policy was revised in the 04/24/2025 major review to focus solely on intrastromal corneal ring segments. As part of that change, corneal surgery procedures and their associated codes were moved to MP 9.011, and computer‑assisted corneal topography codes were moved to MP 5.062.

Use of ICRS for pellucid marginal degeneration or for astigmatism after penetrating keratoplasty is considered investigational. The summary of evidence reports only small case series with limited or mixed results (including reports of no improvement in uncorrected visual acuity and substantial explantation rates), and concludes the evidence is insufficient to demonstrate improved net health outcomes for these indications.

The document sections cited for policy history and revisions do not contain explicit statements framed as “not medically necessary.” Instead, the policy language uses the terms investigational and describes insufficient evidence for certain indications; policy history entries document code and section moves but do not add separate explicit “not medically necessary” declarations in the cited chunks.

Coding: Procedure, Device, and Diagnosis Codes

Covered Procedure CodesCPTCovered

65785

Implantation of intrastromal corneal ring segment(s)

Device/Product Codesmixed

LQE	FDA product code for Intacs (intrastromal corneal ring)

Covered ICD-10 Diagnoses (policy history mentions)ICD-10

H18.711-H18.719	Added ICD-10 codes (corneal dystrophy/keratoconus-related codes) as listed in policy history
S05.00XA-S05.02XS	Added ICD-10 codes (eyelid/eye injury codes) as listed in policy history
H18.501-H18.593, H18.599 etc.	ICD-10 codes previously added/mentioned in earlier administrative update (listed in policy history)

inv-11: Minimum corneal thickness — clinical threshold for incision site

Minimum corneal thickness>= 450 microns at the proposed incision site

Measurement locationThickness specified at the proposed incision site (not central thickness alone)

Clinical implicationCorneal thickness <450 microns at incision site is a denial trigger for keratoconus ICRS coverage

inv-12: Minimum age — clinical threshold for covered indication

Minimum age for covered indication>= 21 years

Regulatory alignmentMatches FDA HDE indication for Intacs in keratoconus patients 21 years or older

Provider Actions, Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for CPT code 65785 (intrastromal corneal ring segment implantation). Requests for this procedure will be reviewed and covered only when medical necessity criteria in the policy are met.

Prior authorization required: CPT 65785

Denial Risk

Denial Triggers for Noncompliant Indications

Requests that do not meet the keratoconus coverage criteria are at risk for denial. Examples of denial triggers include: patient age under 21 years, adequate functional vision achievable with spectacles or rigid gas-permeable (RGP) contact lenses, lack of documented progressive deterioration of vision, or corneal thickness <450 microns at the proposed incision site.

Denial risks: age <21 years
Denial risks: adequate vision with spectacles or RGP lenses

Background and Evidence Summary

Keratoconus is a progressive bilateral corneal dystrophy characterized by paracentral steepening and stromal thinning that leads to irregular astigmatism and impaired visual acuity. Intrastromal corneal ring segments (ICRS) are small crescentic implants placed in corneal stromal channels to flatten or regularize the cornea; they can be inserted via mechanical dissection or femtosecond laser and are removable. ICRS may improve functional vision in select patients with keratoconus and can delay or, in some cases, obviate the need for penetrating keratoplasty when the coverage criteria (including age ≥ 21 years and corneal thickness ≥ 450 microns at the proposed incision site) are met.

Definitions

inv-22: Cornea — definition for glossary

DefinitionThe cornea is the transparent anterior portion of the sclera that refracts light; it is the first part of the eye that refracts light.

Anatomical roleCovers about one sixth of the eyeball surface and is the primary refractive surface of the eye

Relevance to ICRSICRS are implanted within corneal stroma and require a clear central cornea and adequate stromal thickness

inv-23: Keratoconus — definition for glossary

DefinitionKeratoconus is a progressive bilateral dystrophy characterized by paracentral steepening and stromal thinning that impairs visual acuity.

Clinical effectLeads to irregular astigmatism and deterioration of functional vision not fully correctable with spectacles