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CurrentCurativePolicy CHP-IP-2026-241

F114. Corneal Transplantation (Keratoplasty) When Inpatient Care Is Requested

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This policy governs medical necessity for inpatient admission, continued stay, level of care, and discharge readiness when penetrating, anterior lamellar, or endothelial keratoplasty is requested. It applies to adults and children; the keratoplasty procedure itself is generally reviewed under the outpatient ophthalmology policy.

Policy Summary

PayerCurative

PolicyF114. Corneal Transplantation (Keratoplasty) When Inpatient Care Is Requested

Policy CodePolicy N/A

Change TypeAdministrative/version update only

Effective DateNovember 5, 2026

Next Review DateN/A

Key ActionDocument a separate clinical reason supporting inpatient care for any requested keratoplasty admission.

SourceLink

POLICY UPDATE CHANGES

The current version supersedes the prior version and is identified as unchanged between versions.

1–2 daysTypical uncomplicated inpatient stay

24–48 hoursConcurrent review interval

10Discharge readiness criteria

4Continued-stay triggers

5Physician-review scenarios

Outpatient payableKeratoplasty site of care

Inpatient Medical Necessity and Level of Care

Initial inpatient admission

Inpatient admission is medically necessary only when ALL of the following are met.

Admission criteria

Procedure indications
- Endothelial dysfunction: Visually significant corneal edema from endothelial dysfunction, such as Fuchs dystrophy or bullous keratopathy.
- Scarring, opacification, or failed graft: Visually significant corneal scarring or opacification, or failed prior graft.
- Ectasia: Keratoconus or other ectasia when functional vision cannot be achieved with spectacles or contact lenses, or persistent edema after hydrops.

Policy Summary

PayerCurative

PolicyF114. Corneal Transplantation (Keratoplasty) When Inpatient Care Is Requested

Policy CodePolicy N/A

Change TypeAdministrative/version update only

Effective DateNovember 5, 2026

Next Review DateN/A

Key ActionDocument a separate clinical reason supporting inpatient care for any requested keratoplasty admission.

SourceLink

On This Page

Therapeutic indication: Corneal perforation, impending perforation, or infectious keratitis not responding to maximal medical therapy.

Inpatient setting required

Concurrent inpatient procedure: Combined with another procedure that itself meets inpatient criteria, such as open globe repair or vitrectomy for endophthalmitis requiring intravenous or intravitreal therapy with frequent examinations.
Intensive topical therapy unavailable at home: Therapeutic keratoplasty for infectious keratitis requiring hourly or near-hourly topical fortified antimicrobials that the patient cannot administer at home.
High medical or anesthesia risk: ASA physical status IV, or a medical condition requiring post-anesthesia monitoring that cannot be provided in outpatient or observation care.

Outpatient or observation instead of inpatient

Outpatient surgery, with observation of 24 hours or less when needed, is the appropriate level when ANY of the following applies.

Outpatient or observation level

Routine keratoplasty: Routine penetrating, lamellar, or endothelial keratoplasty without an inpatient-setting criterion.
Short postoperative pressure check: Postoperative intraocular pressure check after an air or gas bubble, such as after DMEK, can be completed within hours.

Intensive care unit level

ICU placement is appropriate when ANY of the following is present.

Intensive care criteria

Airway or ventilation: Invasive mechanical ventilation or a new or unstable artificial airway requiring continuous critical-care airway expertise.
Hemodynamic instability: Persistent hypotension after initial fluid resuscitation or any titrated vasopressor or inotrope infusion.SBP <90 mm Hg or MAP <65 mm Hg
Ongoing hemorrhage requiring repeated transfusion, massive transfusion protocol activation, or coagulopathy correction with frequent laboratory titration.
Acute respiratory failure: Severe hypoxemia, escalating high-flow or noninvasive ventilation, or marked respiratory distress.SpO2 <90% despite FiO2 >=0.5; or respiratory rate >30/min with increased work of breathing
Neurologic instability: Severe or worsening neurologic impairment, new focal deficit, or seizures requiring intravenous antiseizure titration.GCS <=8 or fall of >=2 points
Very frequent nursing intervention: Nursing assessment and intervention is needed every hour or more often, exceeding step-down staffing.
Systemic instability from the associated medical condition meets general intensive-care thresholds.

Step-down or intermediate level

Step-down or intermediate care is appropriate when the patient does not meet intensive care criteria and ANY of the following is present.

Step-down or intermediate criteria

Frequent assessments: Vital-sign or focused assessments are required every 2 hours, or hourly for a limited protocol-defined period.
Continuous monitoring or respiratory support: Continuous telemetry or pulse oximetry is required for documented arrhythmia, ischemia, or respiratory risk, or stable noninvasive or high-flow respiratory support is needed.
Frequent infusion monitoring: Non-titrated or slowly titrated infusions such as insulin, heparin, or a weaning antihypertensive infusion require frequent monitoring.
Recent ICU transfer: The patient is within the first 24 hours after ICU transfer and still needs closer monitoring than a medical-surgical unit provides.First 24 hours
Post-anesthesia comorbidity monitoring: A comorbidity requires telemetry or frequent monitoring after anesthesia.

Medical-surgical unit level

A medical-surgical unit is appropriate when the patient does not meet intensive care or step-down criteria and ANY of the following is present.

Medical-surgical criteria

Stable hemodynamics: The patient is hemodynamically stable off vasoactive infusions for at least 12 to 24 hours, with vital signs every 4 hours or less often clinically adequate.12-24 hours off vasoactive infusions
Hospital-level services: Intravenous medications or fluids, parenteral analgesia, drain or wound care beyond home capability, or daily surgical reassessment is still required.
Infectious eye treatment: Hourly topical therapy, intravenous antimicrobials, or frequent examinations are required for infectious keratitis or endophthalmitis.

Discharge readiness

The patient is ready for discharge when ALL of the following are met.

Physiologic stability: Temperature, heart rate, blood pressure, and oxygenation meet the policy thresholds.Temp <38.0 C for >=24 hours; HR <100/min; SBP >=90 mm Hg or baseline; SpO2 >=92% on room air or baseline home oxygen
Pain control: Pain is controlled on an oral or other home-deliverable regimen.
Nutrition: The patient tolerates an oral diet or has a stable enteral or parenteral nutrition plan with supplies and caregiver teaching completed.
Laboratory stability: Laboratory values are stable or trending to baseline, including stable hemoglobin without transfusion for 24 hours and acceptable electrolytes and renal function or an outpatient monitoring plan.No transfusion for 24 hours
Wound and drains: The wound is stable and drains are removed or have acceptable output with documented home drain teaching.
Mobility and post-acute needs: Mobility is at the expected post-procedure level or an appropriate post-acute level of care is arranged.
Safe transition plan: Medications are reconciled; VTE prophylaxis is planned by risk; follow-up, education, return precautions, home health, and durable medical equipment are arranged as needed.Surgeon follow-up within 7-14 days
Ophthalmic stability: Intraocular pressure is controlled, graft or bubble position is acceptable, and the wound is secure.
Topical treatment capability: The patient or caregiver can perform the topical regimen and follow eye-shield and positioning instructions.
Ophthalmology follow-up is scheduled for the next day or as directed.Next day or as directed

Continued-stay criteria

Continued acute inpatient care is medically necessary when ANY of the following is documented.

Ongoing infection treatment: Infectious keratitis or endophthalmitis still requires hourly topical or intravenous therapy and daily examination.
Ocular complication: Uncontrolled intraocular pressure or a wound complication requires inpatient management.
Unmet discharge readiness: Discharge readiness criteria are not met because of a documented, actively treated clinical problem.
Necessary upcoming intervention: A medically necessary procedure or intervention is scheduled within the next 24 hours and cannot safely be performed outpatient.Within 24 hours

Does not meet criteria

The following scenarios do not meet medical-necessity criteria under this policy and are referred for physician review.

Routine inpatient keratoplasty: Routine keratoplasty admission with no inpatient-setting criterion documented.
Convenience preoperative admission: Admission more than 1 day before surgery for scheduling or convenience without a documented medical optimization need.>1 day before surgery
Stay after discharge readiness: Continued acute stay after all discharge readiness criteria are met.
Stay awaiting nonclinical arrangements: Continued stay solely awaiting post-acute placement, transportation, or caregiver availability without an active acute need.
Never a basis for retroactive denial of days already authorized
Unsupported length of stay: Stay beyond the expected length of stay without a documented extended-stay trigger.
Missing clinical information should be requested and the case referred for physician review

Extended-stay review

Extended-stay days beyond the planning benchmark require documentation of the trigger, supporting clinical evidence, and targeted treatment plan.

Extended-stay triggers

Infectious complication: Infectious keratitis or endophthalmitis needs intensive therapy.
Uncontrolled pressure: Intraocular pressure remains uncontrolled.
Wound complication: A wound complication remains under active treatment.
Medical comorbidity: A medical comorbidity requires continued inpatient care.

Inpatient site-of-care rationale

Inpatient keratoplasty requests require the following site-of-care support.

Inpatient site-of-care support: The request is for corneal transplantation and includes a separate, documented reason supporting inpatient care.

Keratoplasty codes are outpatient-payable in the CY 2026 OPPS file.

A preoperative admission more than 1 day before surgery for scheduling or convenience does not meet medical-necessity criteria when there is no documented medical optimization need, such as dialysis, anticoagulation bridging, glucose or volume optimization, or nutrition repletion.

A continued stay solely for post-acute placement, transportation, or caregiver availability does not meet acute-care criteria when no active acute need remains. The case should be referred for physician review and discharge planning; this circumstance is not a basis for retroactive denial of days already authorized.

Routine inpatient keratoplasty without a documented inpatient-setting criterion does not meet medical-necessity criteria because keratoplasty is generally an outpatient procedure. Such requests are referred for physician review rather than automatically denied by an automated system or non-physician reviewer.

A continued acute stay after all discharge-readiness criteria are met is not medically necessary at the acute level. The remaining days are considered custodial or for convenience rather than an active hospital-level need.

A stay beyond the expected length-of-stay benchmark does not meet continued-stay criteria as documented unless a documented extended-stay trigger and supporting clinical information are provided. The usual benchmark for an uncomplicated, justified inpatient case is 1–2 days; exceeding it is not an automatic denial, but requires the missing information and physician review.

Applicable Codes and Review Parameters

ICD-10-CM: KeratoconusICD-10

H18.601	Keratoconus, unspecified, right eye
H18.602	Keratoconus, unspecified, left eye
H18.603	Keratoconus, unspecified, bilateral
H18.609	Keratoconus, unspecified, unspecified eye
H18.611	Keratoconus, stable, right eye
H18.612	Keratoconus, stable, left eye
H18.613	Keratoconus, stable, bilateral
H18.619	Keratoconus, stable, unspecified eye
H18.621	Keratoconus, unstable, right eye
H18.622	Keratoconus, unstable, left eye

1–10 of 12

1/2

ICD-10-CM: Bullous keratopathy, band keratopathy, endothelial corneal dystrophyICD-10

H18.10	Bullous keratopathy, unspecified eye
H18.11	Bullous keratopathy, right eye
H18.12	Bullous keratopathy, left eye
H18.13	Bullous keratopathy, bilateral
H18.421	Band keratopathy, right eye
H18.422	Band keratopathy, left eye
H18.423	Band keratopathy, bilateral
H18.429	Band keratopathy, unspecified eye
H18.511	Endothelial corneal dystrophy, right eye
H18.512	Endothelial corneal dystrophy, left eye

1–10 of 12

1/2

ICD-10-CM: Corneal transplant rejection and failureICD-10

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
T86.8411	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

ICD-10-PCS: Replacement of cornea with nonautologous tissue substituteICD-10

08R8XKZ	Replacement of cornea with nonautologous tissue substitute
08R9XKZ	Replacement of cornea with nonautologous tissue substitute

CPT: KeratoplastyCPT

65710	Keratoplasty, lamellar
65730	Keratoplasty, penetrating
65750	Keratoplasty, penetrating in aphakia
65755	Keratoplasty, penetrating in pseudophakia
65756	Endothelial keratoplasty
65757	Backbench donor endothelial preparation

MS-DRG FY2027 v44: Intraocular proceduresmixed

116	Intraocular procedures with CC/MCC
117	Intraocular procedures without CC/MCC

Revenue codesRevenue

0110-0129	Room and board
0200-0209	Intensive care
0206	Intermediate/step-down
0360-0369	Operating room services
0370	Anesthesia
0710	Recovery room
0110	Revenue code
0111	Revenue code
0112	Revenue code
0113	Revenue code

1–10 of 41

1/5

Inpatient DRG GroupingRevenue

No codes listed

Hemodynamic instability threshold

Systolic blood pressureBelow 90 mm Hg persisting after initial fluid resuscitation

Mean arterial pressureBelow 65 mm Hg persisting after initial fluid resuscitation

Additional ICU criterionAny titrated vasopressor or inotrope infusion also supports intensive care placement

Acute respiratory failure thresholds

OxygenationSpO2 below 90% despite FiO2 of 0.5 or more

Respiratory supportEscalating high-flow or noninvasive ventilation

Respiratory rate and effortRespiratory rate above 30/min with increased work of breathing

Neurologic instability criteria

Glasgow Coma ScaleGCS 8 or less

Change in neurologic statusA fall of 2 or more points or a new focal neurologic deficit

SeizuresSeizures requiring intravenous antiseizure titration

Step-down assessment frequency

Standard frequencyVital-sign or focused assessments every 2 hours

Limited higher-frequency protocolAssessments may be hourly for a limited, protocol-defined period

Level-of-care implicationThe monitoring requirement must exceed medical-surgical capability and not require intensive care

Discharge physiologic stability

TemperatureBelow 38.0 C for at least 24 hours without antipyretic masking

Heart rateBelow 100/min

Blood pressureSystolic blood pressure at least 90 mm Hg or at documented baseline

OxygenationSpO2 at least 92% on room air or the baseline home oxygen prescription

Follow-up timing

Surgeon follow-upWithin 7 to 14 days

Ophthalmology follow-upThe next day or as directed

Transition requirementFollow-up must be scheduled as part of the safe transition plan

Expected length of stay

MS-DRG 116GMLOS 4.0 days with CC/MCC

MS-DRG 117GMLOS 1.9 days without CC/MCC

Uncomplicated justified stayUsually 1 to 2 days when inpatient care is justified

Concurrent review

Medical-surgical or other inpatient staysConcurrent review at least every 24 to 48 hours

Intensive care unit staysConcurrent review daily

Review applicationConcurrent review applies to each continued-stay period

Expected inpatient length of stay

Expected inpatient stay1–2 days

Use of benchmarkThe 1–2 day expectation is supported by the short benchmark for justified inpatient keratoplasty admissions

Longer staysInfectious cases may need longer when supported by clinical documentation

Authorization and Documentation Requirements

Prior Authorization

Admission Requires Indication and Inpatient Need

Approve inpatient keratoplasty only when both a qualifying procedure indication and a qualifying inpatient-setting need are documented.

Procedure indication: meet at least one covered indication, such as visually significant corneal edema from endothelial dysfunction, significant scarring or opacification, failed prior graft, qualifying keratoconus or ectasia, or therapeutic keratoplasty for perforation, impending perforation, or refractory infectious keratitis.
Inpatient setting: meet at least one qualifying inpatient-setting criterion documented below.

Documentation Required

Qualifying Inpatient-Setting Criteria

Document at least one reason the procedure cannot be safely provided in outpatient or observation care.

A concurrent procedure that independently meets inpatient criteria, such as open-globe repair or vitrectomy for endophthalmitis requiring intensive therapy and frequent examinations.
Therapeutic keratoplasty for infectious keratitis requiring hourly or near-hourly fortified topical antimicrobials that the patient cannot administer at home.
ASA physical status IV or a medical condition requiring post-anesthesia monitoring unavailable in outpatient or observation care.

Unsupported block type: prior_auth

Documentation Required

Document the Inpatient Rationale

Because all keratoplasty codes are outpatient-payable, document a separate clinical reason why inpatient care is necessary; the procedure indication alone is insufficient.

State the specific inpatient-setting criterion and the clinical facts supporting it.
Do not rely solely on the keratoplasty procedure or its diagnosis to justify inpatient admission.

Documentation Required

Operative Indication

Support the operative indication with the diagnosis, relevant staging or imaging, and the surgical or multidisciplinary decision to proceed.

Document the condition being treated and its functional or clinical significance.
Include imaging or staging when applicable and record the decision-making leading to surgery.

Documentation Required

Inpatient-Setting Rationale

Identify the specific criterion that requires inpatient care and explain why outpatient or observation care is insufficient.

Specify whether the rationale is a concurrent qualifying inpatient procedure, an infectious emergency requiring intensive treatment, or a medical comorbidity or post-anesthesia monitoring need.
Link the criterion to patient-specific clinical facts.

Documentation Required

Preoperative Risk Assessment

Include the preoperative risk assessment, including ASA physical status and relevant comorbidities.

Record the ASA physical status class.
Describe comorbidities relevant to anesthesia, postoperative monitoring, or the need for inpatient care.

Documentation Required

Procedure and Level-of-Care Plan

Document the planned procedure and codes together with the intended postoperative level of care and the reason for that level.

List planned procedure(s) and applicable CPT and ICD-10-PCS codes.
State the planned postoperative level of care.
Explain why the planned level of care is clinically necessary.

Documentation Required

Daily Acute-Care Documentation

Submit daily progress documentation showing why acute hospital services remain necessary.

Identify the active acute problem.
Describe the hospital-level service delivered.
Document the current treatment plan.

Documentation Required

Clinical Monitoring Records

Maintain clinical monitoring records that support the inpatient level of care and the treatment being provided.

Vital signs.
Intake and output.
Relevant laboratory results.
Procedure-specific monitoring records.

Documentation Required

Extended-Stay Support

For any stay beyond the expected 1–2 day benchmark, document the specific extended-stay trigger and supporting evidence. The benchmark is for planning and is not itself a limit on covered days.

Identify the clinical reason the stay exceeds the expected length.
Provide contemporaneous evidence supporting the trigger and continued inpatient need.

Documentation Required

Discharge Documentation

Document discharge readiness and the transition plan when acute inpatient criteria are met.

Record the discharge readiness assessment.
Include follow-up, patient education, and post-acute services or other transition arrangements.

Unsupported block type: documentation

Prior Authorization

Concurrent-Review Documentation

Support every concurrent-review period and the requested quantity or duration with current clinical documentation.

Submit the active continued-stay trigger for each review period.
Document the quantity, units, or duration requested and the evidence supporting it.
Days already authorized are not retroactively denied; expected length of stay is a planning benchmark, not a coverage limit.

Denial Risk

Routine Keratoplasty Without Inpatient Need

Routine keratoplasty without a documented inpatient-setting criterion does not meet medical-necessity criteria and is considered the wrong site of care.

Keratoplasty is generally an outpatient procedure and its codes are outpatient-payable.
Refer the request for physician review; an automated system or non-physician reviewer may not issue an adverse determination.

Denial Risk

Convenience Preoperative Admission

Do not support a preoperative admission more than one day before surgery for scheduling or convenience without a documented medical optimization need.

Examples of potentially qualifying optimization needs include dialysis, anticoagulation bridging, glucose or volume optimization, or nutrition repletion.
A convenience day without hospital-level service does not meet criteria.

Denial Risk

Stay After Discharge Readiness

Once all discharge-readiness criteria are met, continued acute inpatient care is not medically necessary unless a new qualifying active acute problem is documented.

Days after readiness are considered custodial or for convenience rather than acute care.
Document any new actively treated clinical problem supporting continued stay.

Denial Risk

Nonclinical Discharge Delay

Placement, transportation, or caregiver delays alone do not support continued acute inpatient care when there is no active acute need.

Route the case to physician review and discharge planning.
This circumstance is never a basis for retroactive denial of days already authorized.

Denial Risk

Unsupported Extended Stay

A stay beyond the expected length of stay requires a documented continued-stay or extended-stay trigger and supporting clinical evidence.

Request the missing clinical information when no trigger is documented.
Refer the case for physician review; do not treat the expected length of stay as an automatic coverage limit.

Note

Physician Review for Adverse Determinations

Only a licensed physician of the same or similar specialty may issue an adverse determination, after offering the requesting provider a peer-to-peer discussion.

The reviewing physician must meet applicable licensure, specialty, and medical-director requirements for the plan's situs state.
Automated systems and non-physician reviewers may approve in full or in part but may not issue an adverse determination.

Documentation Required

No Documented Inpatient Rationale

If the record does not separately justify inpatient care, request documentation of the clinical reason the patient requires inpatient rather than outpatient or observation treatment.

A keratoplasty indication alone does not establish inpatient medical necessity.
Apply the qualifying inpatient-setting criteria to the patient-specific facts.

Prior Authorization

Unsupported Quantity or Duration

When the requested quantity, units, or duration exceed what the documentation supports, approve the supported portion and refer only the unsupported increment for physician review.

Do not deny the fully supported portion solely because the total request is excessive.
Concurrent review applies to each continued-stay period.

Clinical Context

Keratoplasty is corneal transplantation used to restore functional vision or address therapeutic conditions. Clinical uses include visually significant endothelial dysfunction, corneal scarring or opacification, failed grafts, and keratoconus or other ectasia when functional vision cannot be achieved with spectacles or contact lenses. Therapeutic keratoplasty may be performed for corneal perforation, impending perforation, or infectious keratitis that does not respond to maximal medical therapy. Because keratoplasty is generally performed on an outpatient basis and the listed procedures are outpatient-payable, an inpatient request requires a separate documented clinical reason for hospital-level care.

Key Terms

Therapeutic keratoplasty

PurposeTo control infection or restore globe integrity rather than primarily for vision

ProcedureKeratoplasty

Clinical roleUsed for therapeutic, rather than primarily visual, treatment

Keratoplasty

DefinitionA surgical procedure involving transplantation of corneal tissue

Visual indicationUsed to restore vision when clinically indicated

Therapeutic indicationsMay treat visually significant edema or opacification and other therapeutic indications

Expected length of stay

Planning expectationExpected length of stay is a planning benchmark for inpatient duration

Coverage-day limitationIt is not a limit on the number of covered inpatient days

Review of longer staysA stay exceeding the benchmark is referred for physician review, not automatically denied