CurrentFidelis CarePolicy CP.VP.36

Keratoplasty (Corneal Transplant) Coverage Criteria

Medical necessity criteria, coding guidance, and supporting clinical information for keratoplasty (corneal transplant) procedures for members of Fidelis Care/Centene-affiliated health plans.

Policy Summary

PayerFidelis Care

PolicyKeratoplasty (Corneal Transplant) Coverage Criteria

Policy CodePolicy CP.VP.36

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization per plan procedures when submitting claims for keratoplasty CPT codes listed in the policy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5+Coded CPT procedures referenced for keratoplasty

~15+ICD-10 diagnosis codes listed to support coverage

11/2024Last review date

Medical Necessity Criteria for Keratoplasty

Covered Indications

Keratoplasty is medically necessary when the member meets ANY of the following indications:

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Procedure and Diagnosis Codes

Covered CPT Codes (referenced)CPT

65730	Keratoplasty (corneal transplant); penetrating (except in aphakia or pseudophakia)
65750	Keratoplasty (corneal transplant); penetrating in aphakia
65755	Keratoplasty (corneal transplant); penetrating in pseudophakia
65756	Keratoplasty (corneal transplant); endothelial
65757	Backbench preparation of corneal endothelial allograft to transplantation (List separately, in addition to code for primary procedure)

ICD-10 Diagnosis Codes Supporting CoverageICD-10

H18.11	Bullous keratopathy, right eye
H18.12	Bullous keratopathy, left eye
H18.621	Keratoconus, unstable, right eye
H18.622	Keratoconus, unstable, left eye
H18.623	Keratoconus, unstable, bilateral
H18.711	Corneal ectasia, right eye
T86.8401	Corneal transplant rejection, right eye
T86.8411	Corneal transplant failure, right eye
T86.8421	Corneal transplant infection, right eye
T85.318A	Breakdown (mechanical) of other ocular prosthetic devices, implants and grafts, initial encounter

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Provider Requirements, Prior Authorization, and Postoperative Care

Prior Authorization

Prior Authorization Required

Prior authorization is required for keratoplasty procedures. Providers must obtain prior authorization for CPT codes describing corneal transplant procedures before scheduling or performing the service to ensure medical necessity review.

Affected codes include CPT 65730, 65750, 65755, 65756, 65757 (see coding guidance).
Prior authorization does not guarantee payment; approval is contingent on meeting medical necessity criteria.

Billing Rule

Coding and Coverage Linkage

Providers must reference current professional coding guidance when selecting codes for keratoplasty and related services. Inclusion or exclusion of codes in this policy is informational only and does not guarantee coverage.

Use the most up-to-date CPT manuals and payer billing instructions when submitting claims.
Codes referenced in this policy include (but are not limited to): CPT 65730, 65750, 65755, 65756, 65757.
Backbench preparation (e.g., CPT 65757) may be reported in addition to the primary procedure when applicable; follow coding conventions and payer-specific rules.

Documentation Required

Postoperative Documentation Requirements

Document postoperative examinations and findings thoroughly. Perform slit-lamp biomicroscopic examinations to assess graft clarity, corneal health, and suture status. Record findings that support medical necessity for follow-up care or treatment of complications.

Document timing and results of slit-lamp exams, including corneal clarity, presence/absence of edema, suture integrity, and any signs of infection.
Record patient education on rejection warning signs (redness, photophobia, vision change, pain) and that the patient was instructed to seek prompt care if symptoms occur.
Note any suture removal (including date and reason) and topographic findings guiding selective suture removal (typically begins ~3 months post-op unless earlier for loose/eroded sutures).

Note

Graft Rejection Recognition and Treatment

Recognize and promptly treat graft rejection. Educate patients on rejection signs and institute appropriate therapeutic pathways when rejection is suspected or confirmed.

Clinical signs to document: epithelial sub‑epithelial infiltrates, stromal edema, endothelial keratic precipitates, endothelial rejection line, and anterior chamber reaction.
First-line treatments include topical corticosteroids; escalation options include oral corticosteroids and periocular corticosteroid injections (subconjunctival or sub‑Tenon’s) as clinically indicated.
Ensure documentation of the clinical rationale, treatment chosen, dose and route of corticosteroid, and response to therapy in the medical record.

Clinical Background

Keratoplasty (corneal transplant) replaces diseased or damaged central corneal tissue with donor tissue to restore or preserve vision. Techniques range from full-thickness penetrating keratoplasty (PK) to lamellar approaches that replace selected layers of the cornea. Endothelial procedures such as Descemet's Stripping Endothelial Keratoplasty (DSEK/DSAEK) and Descemet Membrane Endothelial Keratoplasty (DMEK) selectively replace the diseased endothelial layer, while Deep Anterior Lamellar Keratoplasty (DALK) replaces anterior stromal tissue down to Descemet's membrane and preserves the recipient endothelium. Choice of technique depends on the anatomic layer(s) affected, the underlying diagnosis, and surgeon judgment. Postoperative surveillance for graft clarity, suture management, and early detection of rejection (signs include redness, photophobia, vision change, and pain) is essential to optimize outcomes.

Procedure Definitions

DSEK / DSAEK: definition and concise details

DefinitionDescemet’s Stripping Endothelial Keratoplasty (DSEK/DSAEK) is an endothelial keratoplasty that transplants only a thin portion of posterior corneal tissue (endothelium and Descemet’s membrane) rather than full-thickness corneal grafting.

Clinical advantageAssociated with improved vision outcomes and greater stability, and fewer risk factors compared with full-thickness penetrating keratoplasty (PK), per AAO endorsement noted in the policy.

Indication contextUsed for endothelial disease where replacement of the diseased endothelial layer can restore corneal clarity while preserving anterior corneal structures.

Procedure noteDescribed as a newer surgical method that uses only a very thin portion of the cornea for transplant; may be performed using automated techniques (DSAEK).

Postoperative considerationsAfter keratoplasty, slit-lamp biomicroscopic exams are recommended to assess corneal clarity and health and to monitor for signs of rejection or suture issues.

DALK: definition and concise details

DefinitionDeep Anterior Lamellar Keratoplasty (DALK) is a lamellar keratoplasty that replaces corneal stroma down to Descemet’s membrane while preserving the recipient’s Descemet’s membrane and endothelium.

Appropriate useMost useful for stromal corneal disease when the patient has a normally functioning endothelium (stromal disease with intact endothelium).

Clinical advantageOffers an alternative to penetrating keratoplasty (PK) that may reduce risks of rejection, irregular astigmatism, and corneal opacification associated with full-thickness grafts.

Risk/considerationDALK can carry the potential for decreased visual acuity due to possible opacification at the interface layers between host and donor tissue.

Related techniquesPart of a range of surgical options including ICRS, PK, femtosecond laser-assisted keratoplasty, and other lamellar procedures described in the policy.