Implantation of Intrastromal Corneal Ring Segments
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Medical policy governing when implantation of intrastromal corneal ring segments (ICRS) is considered medically necessary or investigational for Capital Bluecross members; applies to procedures such as Intacs for keratoconus and other indications described.
Policy now only speaks to intrastromal corneal ring segments; corneal surgery codes moved to MP 9.011 and corneal topography codes moved to MP 5.062.
Removed Benefit Variations Section and updated Disclaimer.
Coverage Criteria
Medically necessary: Keratoconus
Covered when ALL of the following are met
Aligned with FDA HDE indication
Initial Coverage Criteria
Covered when medically necessary:
Procedure code 65785 is listed as covered when medical necessity is met
Intrastromal corneal ring segments (ICRS) are considered investigational for the treatment of myopia. The policy states there is insufficient evidence to support a general conclusion about health outcomes or benefits for ICRS when used to treat myopia.
ICRS are considered investigational for all conditions not specified as medically necessary in this policy. The policy explains that, aside from the covered keratoconus indication, available evidence is insufficient to determine an improvement in net health outcome for other indications.
During the 04/24/2025 major review the policy was reorganized to address only intrastromal corneal ring segments. Content and procedure codes related to corneal surgery were moved to MP 9.011 (Corneal Surgery) and content and codes for computer-assisted corneal topography were moved to MP 5.062 (Computer Assisted Corneal Topography); providers should refer to those policies for coverage and coding guidance for those procedures.
Use of ICRS for conditions such as pellucid marginal degeneration and post-penetrating keratoplasty astigmatism has been evaluated in small case series but the evidence is limited and devices used in some reports are not available in the U.S. Available studies have not demonstrated consistent improvement in net health outcome and ICRS for these indications is considered investigational.
Policy history documents administrative updates to ICD-10 coding over time. Historical entries list multiple H18.* diagnosis codes that were added or removed in administrative updates; the history does not enumerate additional specific not-medically-necessary conditions beyond those described in the current policy.
Coding
| 65785 | Implantation of intrastromal corneal ring segment(s) (ICRS) |
| LQE | FDA product code for intrastromal corneal ring devices |
| 65785 | Implantation of intrastromal corneal ring segment(s) |
Provider Actions & Requirements
Prior authorization required; affected code 65785
Prior authorization is required when services are subject to medical policy review and member benefit determination; CPT code 65785 (implantation of intrastromal corneal ring segment[s]) is listed in the coding section as a procedure subject to coverage determination.
- Prior authorization required when service is subject to review and member benefit determination.
- Affected CPT code: 65785 (implantation of intrastromal corneal ring segment[s]).
Prior authorization required for ICRS (CPT 65785)
Prior authorization must be obtained when billing the listed procedure code(s) for intrastromal corneal ring segment implantation; coverage is provided only when the procedure meets the policy's medically necessary criteria.
- Coverage of CPT 65785 is contingent on meeting the "Covered when medically necessary" criteria in the policy.
- Obtain prior authorization before billing to confirm member benefits and medical necessity.
Attempt rigid contact lenses before ICRS
Conservative management—typically rigid (hard) contact lenses—should be attempted prior to consideration of intrastromal corneal ring segments for keratoconus.
- Initial treatment for keratoconus often consists of hard contact lenses; consider ICRS only after conservative measures are inadequate.
Preserve source text for policy writer.
Required clinical documentation for covered keratoconus
Document clinical findings that satisfy the covered keratoconus criteria: patient age (≥21 years), progressive deterioration in vision despite contact lenses or spectacles, a clear central cornea, and corneal thickness of 450 microns or greater at the proposed incision site.
- Patient age ≥ 21 years.
- Progressive vision deterioration such that adequate functional vision cannot be achieved with contact lenses or spectacles.
- Clear central cornea.
- Corneal thickness ≥ 450 microns at the proposed incision site.
Document medical necessity tied to covered procedure codes
Provider must document medical necessity for implantation of intrastromal corneal ring segments tied to the listed procedure code(s) and reference the policy when submitting authorization requests or claims.
- Document how the case meets the "Covered when medically necessary" elements of the policy for CPT 65785.
- Reference MP 1.044 in authorization requests and supporting documentation after the 2025 reorganization.
Investigational indications may be denied (e.g., myopia)
Requests for ICRS to treat myopia, or for indications not specified as medically necessary in the policy, may be denied as investigational.
- ICRS considered investigational for myopia.
- ICRS considered investigational for conditions not listed as medically necessary due to insufficient evidence.
Medical necessity required for payment; risk of denial if criteria not met
Claims and authorization requests for CPT 65785 may be denied if the procedure does not meet the policy's "Covered when medically necessary" criteria associated with that code.
- Ensure all covered-when-medically-necessary elements (age, progressive vision loss, clear central cornea, corneal thickness ≥450 microns, corneal transplantation as the only alternative) are documented.
- Failure to document these criteria can result in denial of payment.
Background
Keratoconus is a progressive corneal ectatic disorder characterized by stromal thinning and irregular astigmatism that can impair visual acuity. Initial management typically uses conservative measures such as rigid (hard) contact lenses; in advanced cases penetrating keratoplasty has been a traditional option. Intrastromal corneal ring segments are small arc-shaped implants placed in stromal channels to flatten and regularize the cornea and may be removable. For keratoconus, this policy provides a covered indication when specific criteria are met (see coverage criteria), and prior authorization and documentation demonstrating medical necessity are required when billing the covered procedure code.
Definitions
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