ModifiedHealth-New-EnglandPolicy UM671POL

Corneal Remodeling for Refractive Errors and Corneal Grafting and Transplantation

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This policy governs coverage for corneal crosslinking, intrastromal corneal ring segments, corneal relaxing incisions, corneal wedge resection, amniotic membrane transplantation, limbal stem cell transplantation, corneal stromal lenticule transplantation, and related ocular grafting procedures for Health New England Commercial, Medicare Advantage, and Medicaid members.

Policy Summary

PayerHealth-New-England

PolicyCorneal Remodeling for Refractive Errors and Corneal Grafting and Transplantation

Policy CodePolicy UM671POL

Change TypeModified

Effective DateFebruary 1, 2027

Last ReviewSep 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization for corneal crosslinking, corneal relaxing or wedge procedures, intrastromal ring segments, and covered ocular-surface or limbal graft procedures.

SourceLink

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ModifiedHealth-New-EnglandPolicy UM671POL

Corneal Remodeling for Refractive Errors and Corneal Grafting and Transplantation

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Policy Summary

PayerHealth-New-England

PolicyCorneal Remodeling for Refractive Errors and Corneal Grafting and Transplantation

Policy CodePolicy UM671POL

Change TypeModified

Effective DateFebruary 1, 2027

Last ReviewSep 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization for corneal crosslinking, corneal relaxing or wedge procedures, intrastromal ring segments, and covered ocular-surface or limbal graft procedures.

SourceLink

POLICY UPDATE CHANGES

The policy added medical-necessity criteria for corneal grafting and amniotic membrane transplantation, corneal stromal lenticule transplantation, limbal stem cell transplantation, and sural nerve grafting for ocular indications.

Prior authorization was added for CPT 65772.

The policy established refractive-disorder coding rules under which CPT 65710, 65730, 65750, and 65755 deny as not medically necessary.

CPT 65760 was identified as experimental or investigational, and CPT 65765 denies as experimental or investigational when billed with a diagnosis of refractive disorder.

4New ocular-indication service categories

9Covered procedures requiring prior authorization

4Refractive-disorder codes not medically necessary

2Refractive-disorder codes experimental or investigational

3Standard amniotic membrane applications per eye

Medical Necessity and Coverage Criteria

Corneal Crosslinking

Covered when the qualifying indication and all additional criteria are met.

ALL of the following

ONE of the following indications
- Progressive keratoconus.
- Corneal ectasia following refractive surgery.
Conventional, epithelium-off corneal collagen crosslinking (C-CXL) is performed using an FDA-approved drug/device system, such as Photrexa Viscous or Photrexa with the KXL System (CPT 0402T).
ALL of the following additional criteria
- Member is 14 through 65 years of age.14–65 years
- Progressive deterioration in vision.
- No visual disturbance from a significant central corneal opacity or other eye disease, such as herpetic keratitis or neurotrophic keratopathy.

Intrastromal Corneal Ring Segments

Covered when performed in accordance with all FDA Humanitarian Device Exemption specifications and all criteria below are met.

ALL of the following

Intrastromal corneal ring segment insertion, such as INTACS prescription inserts, is performed for myopia and astigmatism in a patient with keratoconus (CPT 65785).
Progressive deterioration in vision such that adequate daily functional vision with contact lenses or spectacles can no longer be achieved.
Member is 21 years of age or older.≥ 21 years
Clear central corneas.
Corneal thickness is at least 450 microns at the proposed incision site.

Corneal Relaxing Incisions and Corneal Wedge Resection

Covered when all applicable medical-necessity criteria are met.

ALL of the following

Correction of surgically induced astigmatism of 3.00 diopters or greater with a corneal relaxing incision (CPT 65772) or corneal wedge resection (CPT 65775), also known as astigmatic keratotomy.
ONE of the following surgical settings
- Post-cataract surgery.
- Post-corneal transplant surgery.
Member is intolerant of glasses or contact lenses.
Procedures for any other indication are not medically necessary.

Limbal Deficiency Reconstruction

Covered for ocular surface reconstruction when limbal deficiency is refractory to conventional treatment and the applicable unilateral or bilateral condition is present.

ALL of the following

Preserved human amniotic membrane transplantation or limbal stem cell transplantation is used for ocular surface reconstruction.
Limbal deficiency (hypofunction or total loss of stem cells) is refractory to conventional treatment.
ONE of the following condition groups
- Total loss of stem cells; unilateral involvement only
  - ANY of the following
    Chemical or thermal injury of the ocular surface.

Other Covered Amniotic Membrane Indications

Covered for the specified ocular surface conditions when the applicable criteria are met.

ANY of the following covered indications

Conjunctivochalasis after conservative therapies, such as artificial tear drops and antibiotic/steroid drops, have failed.
Symblepharon; preserved human amniotic membrane transplantation or limbal stem cell transplantation is medically necessary.
After wide excision of a conjunctival neoplasm; amniotic membrane graft is medically necessary.

Experimental and Investigational Procedures

The following procedures are experimental and investigational because their effectiveness has not been established.

ANY of the following procedures or indications

Allogeneic corneal epithelial stem cell transplantation for limbal stem cell deficiency and other indications.
Amniotic membrane placement following superficial keratectomy or phototherapeutic keratectomy (PTK) to treat recurrent corneal erosions.
Amniotic membrane transplantation for conjunctival flap covering surgery of corneal perforations in fungal keratitis.
Amniotic membrane transplantation for age-related macular degeneration.
Combined amniotic membrane transplantation and umbilical amnion for infectious scleritis.

Refractive Procedures Not Medically Necessary

The following refractive procedures are not medically necessary.

ANY of the following

Conductive keratoplasty (CPT 66999).
Lamellar keratoplasty (non-penetrating keratoplasty) (CPT 65710 or 66999).
Laser thermokeratoplasty (LTK) (CPT 66999).
Limbal relaxing incisions for non-surgically induced astigmatism (CPT 66999).
Penetrating keratoplasty (PK), including corneal transplantation or perforating keratoplasty (CPT 65730, 65750, 65755, or 66999).

Refractive Procedures Experimental and Investigational

The following refractive procedures are experimental and investigational.

ANY of the following

Automated lamellar keratomileusis (ALK), also known as standard keratomileusis, for all refractive errors (CPT 65760).
Corneal inlay (CPT 66999).
Hexagonal keratotomy in all cases (CPT 66999).
Keratophakia for correction of all refractive errors (CPT 65765).
Minimally invasive radial keratotomy (mini-RK) in all cases (CPT 66999).

Experimental Ocular-Surface and Limbal Procedures

The following ocular-surface, limbal, and related procedures or indications are experimental and investigational.

ANY of the following indications

Amniotic membrane transplantation or limbal stem cell transplantation for gelatinous drop-like corneal dystrophy, also known as subepithelial amyloidosis of the cornea.
Amniotic membrane transplantation or limbal stem cell transplantation for restrictive strabismus.
Amniotic membrane transplantation or limbal stem cell transplantation for retinal detachment.
Amniotic membrane transplantation or limbal stem cell transplantation in trabeculectomy for primary open-angle glaucoma.

Added Ocular-Indication Criteria

The following added ocular-indication criteria apply to the specified services.

Covered ocular indications when the applicable criteria are met

Refractory limbal deficiency meeting the unilateral total-loss or unilateral/bilateral hypofunction criteria listed under Limbal Deficiency Reconstruction.
Conjunctivochalasis after failure of conservative therapy.
Symblepharon.
Amniotic membrane graft after wide excision of a conjunctival neoplasm.

Epithelium-on, transepithelial, and other corneal collagen crosslinking procedures are experimental and investigational, including procedures other than conventional, epithelium-off C-CXL performed with an FDA-approved drug/device system.

Amniotic membrane placement for recurrent corneal erosions and epithelial basement membrane dystrophy is not medically necessary, including placement intended to treat recurrent erosions or prevent new erosions in members with epithelial basement membrane dystrophy (EMBD).

The following are experimental and investigational: allogeneic corneal epithelial stem cell transplantation; amniotic membrane placement after superficial keratectomy or PTK for recurrent corneal erosions; amniotic membrane transplantation for fungal-keratitis corneal perforation flap covering, age-related macular degeneration, infectious scleritis with umbilical amnion, corneal alkali burns with heparinized membrane and growth factors, and prophylaxis against graft rejection with HLA-matched limbal stem cells; corneal stromal lenticule transplantation for corneal ulcers; double-layer amniotic membrane transplantation for conjunctival tube erosion; human amniotic membrane plug for macular hole or macular hole retinal detachment; Neox Flo micronized amniotic membrane for dry eye, punctate keratitis, or meibomian gland dysfunction; sural nerve grafting for neurotrophic keratitis; tectonic amniotic membrane transplantation for fungal keratitis biopsy debulking; and amniotic membrane or limbal stem cell transplantation for gelatinous drop-like corneal dystrophy, restrictive strabismus, retinal detachment, or trabeculectomy for primary open-angle glaucoma.

Double-layer amniotic membrane transplantation is not covered under CPT 65780.

The H16.8 category is not covered for neurotrophic keratitis or fungal keratitis.

CPT 65710, 65730, 65750, and 65755 deny as not medically necessary when billed with a diagnosis of refractive disorder.

CPT 65765 denies as experimental and investigational when billed with a diagnosis of refractive disorder.

Conventional corneal collagen crosslinking is not medically necessary for indications other than progressive keratoconus or corneal ectasia following refractive surgery, including when combined with a second refractive procedure.

Intrastromal corneal ring segments are not medically necessary for indications other than FDA HDE-qualified keratoconus with progressive visual deterioration, age 21 years or older, clear central corneas, corneal thickness of at least 450 microns at the incision site, and corneal transplantation as the only remaining option for functional improvement.

Corneal relaxing incisions and corneal wedge resections are not medically necessary for indications other than surgically induced astigmatism of at least 3.00 diopters after cataract or corneal transplant surgery in a member intolerant of glasses or contact lenses.

More than three applications per eye of any human amniotic membrane graft for ophthalmic indications per year are not medically necessary. An additional three applications per eye per year in each subsequent year may be medically necessary for chronic or recurrent ophthalmic conditions that have failed conservative treatment when supported by clinical documentation from the treating provider.

Conductive keratoplasty, non-penetrating lamellar keratoplasty, laser thermokeratoplasty, limbal relaxing incisions for non-surgically induced astigmatism, penetrating keratoplasty, LASEK, and orthokeratology are classified as not medically necessary under the listed codes.

Corneal transplantation procedures classified as not medically necessary include anterior lamellar keratoplasty and penetrating keratoplasty, including procedures billed under CPT 65710, 65730, 65750, 65755, and 66999.

CPT 65710, 65730, 65750, and 65755 deny as not medically necessary when billed with a diagnosis of refractive disorder; CPT 65765 denies as experimental and investigational with a refractive-disorder diagnosis.

Procedure and Diagnosis Coding

Covered CPT Code - Corneal CrosslinkingCPTCovered

0402T

Conventional, epithelium-off, corneal collagen crosslinking using an FDA-approved drug/device system

Covered CPT Code - Intrastromal Corneal Ring SegmentsCPTCovered

65785

Insertion of intrastromal corneal ring segments

Covered CPT Codes - Corneal Relaxing/Wedge ProceduresCPTCovered

65772	Corneal relaxing incision
65775	Corneal wedge resection

Not Medically Necessary - Corneal CrosslinkingCPTNot Covered

0402T

Corneal collagen crosslinking when used for an unqualified indication or combined with a second refractive procedure

Not Medically Necessary - Intrastromal Corneal Ring SegmentsCPTNot Covered

65785

Intrastromal corneal ring segment insertion for indications other than the specified keratoconus HDE criteria

Not Medically Necessary - Corneal Relaxing/Wedge ProceduresCPTNot Covered

65772	Corneal relaxing incision for an indication other than qualifying surgically induced astigmatism
65775	Corneal wedge resection for an indication other than qualifying surgically induced astigmatism

Covered CPT and HCPCS CodesmixedCovered

0402T	Collagen crosslinking of cornea including removal of the corneal epithelium, when performed, and intraoperative pachymetry
65772	Corneal relaxing incision for correction of surgically induced astigmatism
65775	Corneal wedge resection for correction of surgically induced astigmatism
65785	Implantation of intrastromal corneal ring segments
65778	Placement of amniotic membrane on the ocular surface; without sutures
65779	Placement of amniotic membrane on the ocular surface; single layer, sutured
65780	Ocular surface reconstruction; amniotic membrane transplantation, multiple layers
V2790	Amniotic membrane for surgical reconstruction, per procedure ocular surface reconstruction
65781	Ocular surface reconstruction; limbal stem cell allograft, such as cadaveric or living donor
65782	Limbal conjunctival autograft, including obtaining graft

Not Medically Necessary or Not Covered CodesmixedNot Covered

65710	Keratoplasty (corneal transplant); anterior lamellar
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
66999	Unlisted procedure, anterior segment of eye
V2599	Contact lens, other type

Experimental and Investigational CodesCPTExperimental

65760	Keratomileusis
65765	Keratophakia
66999	Unlisted procedure, anterior segment of eye, when used to describe procedures in the experimental and investigational section

ICD-10 Refractive-Error CodesICD-10

H52.0	Hypermetropia
H52.1	Myopia
H52.2	Astigmatism
H52.3	Anisometropia and aniseikonia
H52.4	Presbyopia
H52.6	Other disorders of refraction
H52.7	Unspecified disorder of refraction

ICD-10 Codes Applicable to Ocular-Surface and Corneal ProceduresICD-10

B00.50	Herpesviral ocular disease, unspecified
B00.52	Herpesviral keratitis
B00.59	Other herpesviral disease of eye
B00.9	Herpesviral infection, unspecified
B02.33	Zoster keratitis
B60.13	Keratoconjunctivitis due to Acanthamoeba
C69.00	Malignant neoplasm of unspecified conjunctiva
C69.01	Malignant neoplasm of right conjunctiva
C69.02	Malignant neoplasm of left conjunctiva
C69.11	Malignant neoplasm of right cornea

1–10 of 47

1/5

Prior AuthorizationCPT

65772

CPT code identified as requiring prior authorization; procedure description not provided in this window.

Not Medically Necessary for Refractive DisorderCPTNot Covered

65710	Denies as not medically necessary when billed with a diagnosis of refractive disorder.
65730	Denies as not medically necessary when billed with a diagnosis of refractive disorder.
65750	Denies as not medically necessary when billed with a diagnosis of refractive disorder.
65755	Denies as not medically necessary when billed with a diagnosis of refractive disorder.

Experimental or InvestigationalCPTExperimental

65760	Added to the policy and identified as currently experimental or investigational.
65765	Denies as experimental or investigational when billed with a diagnosis of refractive disorder.

Intrastromal Corneal Ring Segment Age Requirement

Minimum age21 years or older

ProcedureInsertion of intrastromal corneal ring segments

Covered indicationKeratoconus-associated myopia and astigmatism meeting FDA Humanitarian Device Exemption specifications

Intrastromal Corneal Ring Segment Corneal Thickness

Authorization, Documentation, and Denial Rules

Note

Line-of-Business Criteria

For Commercial members, refer to the criteria under the Policy section. For Medicaid (BeHealthy), refer to the Policy criteria; no MassHealth guidelines are available for corneal remodeling. For Medicare members, apply the applicable InterQual criteria for refractive keratoconus.

Prior Authorization

Prior Authorization Required: Corneal Collagen Crosslinking

Prior authorization is required for corneal collagen crosslinking, including CPT 0402T.

CPT 0402T — Collagen crosslinking of cornea, including removal of corneal epithelium when performed and intraoperative pachymetry.

Prior Authorization

Prior Authorization Required: Corneal Remodeling

Clinical Background

Refractive errors occur when the eye does not focus incoming light on the retina. They include myopia, hyperopia, astigmatism, and presbyopia. Keratoconus and post-refractive-surgery corneal ectasia may involve progressive corneal thinning or distortion, causing irregular astigmatism, progressive myopia, and visual loss.

Key Terms

Keratoconus

DefinitionA non-inflammatory degenerative condition in which corneal collagen fibers weaken and progressively thin

Corneal changesThe cornea bulges outward, steepens, and develops a progressive conical shape

Clinical effectsIrregular astigmatism and progressive myopia or visual loss

Corneal Ectasia

DefinitionA group of corneal conditions involving irregularities that disturb vision through astigmatism

Related conditionKeratoconus

Postsurgical association

Policy Summary

PayerHealth-New-England

PolicyCorneal Remodeling for Refractive Errors and Corneal Grafting and Transplantation

Policy CodePolicy UM671POL

Change TypeModified

Effective DateFebruary 1, 2027

Last ReviewSep 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization for corneal crosslinking, corneal relaxing or wedge procedures, intrastromal ring segments, and covered ocular-surface or limbal graft procedures.

SourceLink

On This Page

Corneal transplantation is the only other remaining option for improving functional vision.

Contact lens-induced keratopathy or toxic effects from lens-cleaning solutions.

Corneal limbal dermoid.

Multiple surgeries or cryotherapies to the limbal region.

Stevens-Johnson syndrome.

Hypofunction of stem cells; unilateral or bilateral involvement

ANY of the following
- Hereditary aniridia.
- Bacterial keratitis.
- Bullous keratopathy.
- Chronic limbitis.
- Keratitis associated with multiple endocrine deficiency (hereditary).
- Neurotrophic keratopathy (neuronal or ischemic).
- Peripheral corneal ulcerative keratitis, including Mooren's ulcer.
- Primary or recurrent pterygium and pseudopterygium.

Combined heparinized amniotic membrane with growth factors for corneal alkali burns.

Combined HLA-matched limbal stem cell allograft with amniotic membrane transplantation as a prophylactic approach to prevent corneal graft rejection following penetrating keratoplasty.

Corneal stromal lenticule transplantation for corneal ulcers.

Double-layer amniotic membrane transplantation for conjunctival tube erosion.

Human amniotic membrane plug for macular hole and macular hole retinal detachment.

Neox Flo micronized amniotic membrane for dry eye, punctate keratitis, and meibomian gland dysfunction.

Sural nerve grafting for neurotrophic keratitis.

Tectonic amniotic membrane transplantation for debulking corneal biopsy in fungal keratitis.

Laser epithelial keratomileusis (LASEK) (CPT 66999).

Orthokeratology in all cases (HCPCS V2599).

Scleral expansion surgery (CPT 66999).

Minimum corneal thickness450 microns or greater

Measurement siteAt the proposed incision site

Additional anatomic requirementClear central corneas

Corneal Relaxing Incision or Wedge Resection Threshold

Minimum astigmatism3.00 diopters or greater

CauseSurgically induced astigmatism after cataract or corneal transplant surgery

Patient requirementIntolerance of glasses or contact lenses

Standard Amniotic Membrane Graft Application Limit

Standard limitMore than 3 applications per eye is not medically necessary

Applies toAny human amniotic membrane graft for ophthalmic indications

Policy rationaleReliable data demonstrating improved clinical outcomes with more frequent application are limited

Additional Amniotic Membrane Graft Applications

Additional allowanceAn additional 3 applications per eye per year may be medically necessary in each subsequent year

Qualifying conditionsChronic or recurrent ophthalmic conditions

Required supportFailure of conservative treatment and clinical documentation from the treating provider

Prior authorization is required for corneal remodeling procedures used to correct surgically induced astigmatism or treat eligible corneal conditions.

CPT 65772 — Corneal relaxing incision.
CPT 65775 — Corneal wedge resection.
CPT 65785 — Implantation of intrastromal corneal ring segments.

Prior Authorization

Prior Authorization Required: Ocular-Surface and Limbal Grafts

Prior authorization is required for ocular-surface reconstruction and limbal procedures, including covered amniotic membrane and limbal graft services.

CPT 65778 — Amniotic membrane placement on the ocular surface, without sutures.
CPT 65779 — Single-layer sutured amniotic membrane placement.
CPT 65780 — Ocular surface reconstruction with multiple-layer amniotic membrane transplantation; not covered for double-layer transplantation.
HCPCS V2790 — Amniotic membrane for surgical reconstruction.
CPT 65781 — Ocular surface reconstruction with limbal stem-cell allograft.
CPT 65782 — Limbal conjunctival autograft.

Prior Authorization

Prior Authorization Required: CPT 65772

Prior authorization is required when billing CPT 65772.

CPT 65772 — Corneal relaxing incision for correction of surgically induced astigmatism.

Documentation Required

Document Medical Necessity for Crosslinking

For conventional, epithelium-off corneal collagen crosslinking with an FDA-approved drug/device system, document a qualifying diagnosis and all required clinical findings.

Progressive keratoconus or corneal ectasia following refractive surgery.
Member age 14–65 years.
Progressive deterioration in vision.
No visual disturbance from a significant central corneal opacity or other eye disease, such as herpetic keratitis or neurotrophic keratopathy.
Identify the FDA-approved drug/device system used, such as Photrexa® with the KXL® System.

Documentation Required

Document Medical Necessity for Intrastromal Ring Segments

For CPT 65785, document that the procedure is performed under the FDA Humanitarian Device Exemption specifications and that every medical-necessity criterion is met.

Keratoconus with progressive deterioration such that adequate daily functional vision can no longer be achieved with contact lenses or spectacles.
Age 21 years or older.
Clear central corneas.
Corneal thickness of at least 450 microns at the proposed incision site.
Corneal transplantation is the only remaining option for improving functional vision.

Documentation Required

Document Medical Necessity for Astigmatism Correction

For corneal relaxing incision or wedge resection, document the qualifying postoperative indication and the member’s inability to tolerate corrective lenses.

Surgically induced astigmatism of at least 3.00 diopters.
Astigmatism is post-cataract or post-corneal-transplant surgery.
Member is intolerant of glasses or contact lenses.
Report the applicable procedure: CPT 65772 or CPT 65775.

Documentation Required

Document Medical Necessity for Ocular-Surface Reconstruction

For ocular-surface reconstruction, document limbal deficiency, failure of conventional treatment, and the qualifying cause of stem-cell loss or hypofunction.

Limbal deficiency with hypofunction or total loss of stem cells, refractory to conventional treatment.
For total stem-cell loss with unilateral involvement, document a qualifying cause such as chemical or thermal injury, contact-lens-induced keratopathy or toxic lens-cleaning effects, corneal limbal dermoid, multiple limbal surgeries or cryotherapies, or Stevens-Johnson syndrome.
For stem-cell hypofunction, document a qualifying condition such as hereditary aniridia, bacterial keratitis, bullous keratopathy, chronic limbitis, neurotrophic keratopathy, peripheral corneal ulcerative keratitis, pterygium, or pseudopterygium.
For conjunctivochalasis, document failure of conservative therapy. Also document qualifying symblepharon, post-neoplasm excision, or other covered ocular-surface indication when applicable.

Documentation Required

Submit Supporting Clinical and Procedure Documentation

Submit clinical records that support both the procedure reported and the covered indication. Documentation should allow the plan to verify the diagnosis, clinical findings, treatment history, and applicable coverage criteria.

Procedure note and the specific CPT or HCPCS code billed.
Diagnosis and clinical findings supporting the covered indication.
Relevant measurements, examination findings, imaging, treatment history, and failed conservative therapy when required.
For graft and ocular-surface procedures, identify the graft type, number of layers or applications, laterality, and indication.
Ensure the requested service is consistent with the policy’s covered procedure and coding guidance.

Billing Rule

Support Diagnosis Coding

Prior authorization is required for the listed covered procedures, but authorization does not guarantee payment. Confirm that diagnosis coding supports the applicable covered indication and member benefit.

CPT 0402T — Corneal collagen crosslinking.
CPT 65772 — Corneal relaxing incision.
CPT 65775 — Corneal wedge resection.
CPT 65785 — Intrastromal corneal ring segments.
CPT 65778, 65779, 65780, 65781, and 65782 — Covered ocular-surface and limbal procedures when policy criteria are met.
HCPCS V2790 — Amniotic membrane for surgical reconstruction.
Applicable diagnosis coding may include refractive disorders H52.0–H52.7 and covered ocular-surface diagnoses such as symblepharon, pseudopterygium, conjunctivochalasis, corneal ulcer, neurotrophic keratoconjunctivitis, bullous keratopathy, contact-lens corneal disorder, Stevens-Johnson syndrome, aniridia, ocular burns, and corneal dermoid.

Documentation Required

Submit Clinical Evidence With the Request

The treating physician or primary care provider must submit clinical evidence showing that the patient meets the policy criteria. Without supporting documentation, Health New England cannot properly review the prior authorization request.

Submit clinical evidence with every applicable prior authorization request.
Documentation must support medical necessity, the requested treatment or procedure, and the covered indication.
Benefit coverage remains subject to the member’s specific benefit program and applicable law.

Denial Risk

Noncovered or Investigational Crosslinking

Conventional epithelium-off crosslinking is covered only for progressive keratoconus or corneal ectasia following refractive surgery when all stated criteria are met. Crosslinking for other indications is not medically necessary, and other techniques are experimental and investigational.

C-CXL combined with a second refractive procedure is not medically necessary.
Crosslinking for any indication other than progressive keratoconus or post-refractive-surgery corneal ectasia is not medically necessary.
Epithelium-on or trans-epithelial and other nonqualifying crosslinking procedures are experimental and investigational.
Claims may be denied when the indication, technique, age, progression, or visual findings do not meet the policy.

Denial Risk

Ring Segments Outside HDE Criteria

Intrastromal corneal ring segments are medically necessary only when provided under FDA HDE specifications and all listed criteria are satisfied. Other indications are not medically necessary.

Claims may be denied when there is no documented progressive functional-vision loss despite contact lenses or spectacles.
Member must be at least 21 years old, have clear central corneas, and have at least 450 microns of corneal thickness at the incision site.
Document that corneal transplantation is the only remaining option for improving functional vision.

Denial Risk

Astigmatism Procedure Outside Covered Indication

Corneal relaxing incision and wedge resection are covered only for surgically induced astigmatism of at least 3.00 diopters after cataract or corneal-transplant surgery in a member intolerant of glasses or contact lenses.

Nonqualifying relaxing incision or wedge resection may be denied as not medically necessary.
Limbal relaxing incisions for non-surgically induced astigmatism are not medically necessary under the policy.
CPT 65772 and CPT 65775 require documentation of the covered indication.

Denial Risk

Amniotic Membrane Application Limit

More than three applications per eye of a human amniotic membrane graft for ophthalmic indications are not medically necessary unless the policy exception is supported by clinical documentation.

An additional three applications per eye per year may be medically necessary for chronic or recurrent ophthalmic conditions that failed conservative treatment.
Document the condition, failed conservative treatment, application history, and treating provider’s clinical justification for the exception.

Denial Risk

EMBD Recurrent Erosion Exclusion

Amniotic membrane placement is not medically necessary to treat recurrent corneal erosions or prevent new erosions in members with epithelial basement membrane dystrophy (EMBD).

Claims for this EMBD indication may be denied as not medically necessary.
This exclusion applies even when the purpose is treatment or prevention of recurrent corneal erosions.

Denial Risk

Experimental Transplantation Procedures

The listed transplantation and grafting approaches are experimental and investigational because their effectiveness has not been established.

Allogeneic corneal epithelial stem-cell transplantation.
Amniotic membrane placement after superficial keratectomy or PTK for recurrent corneal erosions.
Amniotic membrane transplantation for conjunctival flap covering of corneal perforations in fungal keratitis or for age-related macular degeneration.
Combined amniotic membrane and umbilical amnion for infectious scleritis; combined heparinized amniotic membrane with growth factors for corneal alkali burns; and combined HLA-matched limbal stem cells with amniotic membrane to prevent graft rejection.
Corneal stromal lenticule transplantation for corneal ulcers; double-layer amniotic membrane transplantation for conjunctival tube erosion; and human amniotic membrane plug for macular hole or macular hole retinal detachment.
Neox Flo micronized amniotic membrane for dry eye, punctate keratitis, or meibomian gland dysfunction; sural nerve grafting for neurotrophic keratitis; and tectonic amniotic membrane transplantation for debulking corneal biopsy in fungal keratitis.
Amniotic membrane or limbal stem-cell transplantation for gelatinous drop-like corneal dystrophy, restrictive strabismus, retinal detachment, or trabeculectomy for primary open-angle glaucoma.

Denial Risk

Refractive Procedures Not Medically Necessary

The following refractive procedures are classified as not medically necessary under the policy; claims may be denied when billed for these services.

Conductive keratoplasty — CPT 66999.
Lamellar keratoplasty, including non-penetrating keratoplasty — CPT 65710 or 66999.
Laser thermokeratoplasty — CPT 66999.
Limbal relaxing incisions for non-surgically induced astigmatism — CPT 66999.
Penetrating keratoplasty or corneal transplantation — CPT 65730, 65750, 65755, or 66999.
Laser epithelial keratomileusis (LASEK) — CPT 66999.
Orthokeratology in all cases — HCPCS V2599.

Denial Risk

Experimental Refractive Procedures

The following refractive procedures are classified as experimental and investigational; claims may be denied under the policy.

Automated lamellar keratomileusis (ALK) — CPT 65760.
Corneal inlay — CPT 66999.
Hexagonal keratotomy — CPT 66999.
Keratophakia for correction of refractive errors — CPT 65765.
Minimally invasive radial keratotomy (mini-RK) — CPT 66999.
Scleral expansion surgery — CPT 66999.

Denial Risk

Experimental Amniotic Membrane and Related Applications

The listed amniotic membrane, limbal stem-cell, lenticule, and related applications are experimental and investigational because effectiveness has not been established; claims may be denied.

Includes amniotic membrane applications for recurrent erosions after superficial keratectomy or PTK, fungal-keratitis perforation coverage, age-related macular degeneration, infectious scleritis, corneal alkali burns, graft-rejection prophylaxis, conjunctival tube erosion, macular hole, dry eye, punctate keratitis, meibomian gland dysfunction, and fungal-keratitis biopsy debulking.
Includes allogeneic corneal epithelial stem-cell transplantation, corneal stromal lenticule transplantation for corneal ulcers, and sural nerve grafting for neurotrophic keratitis.
Includes specified amniotic membrane or limbal stem-cell transplant applications for gelatinous drop-like corneal dystrophy, restrictive strabismus, retinal detachment, and trabeculectomy.

Denial Risk

Refractive-Disorder Diagnosis With Specified Graft Codes

When CPT 65710, 65730, 65750, or 65755 is billed with a diagnosis of refractive disorder, the claim will deny as not medically necessary.

CPT 65710 — Anterior lamellar keratoplasty.
CPT 65730 — Penetrating keratoplasty, except in aphakia or pseudophakia.
CPT 65750 — Penetrating keratoplasty in aphakia.
CPT 65755 — Penetrating keratoplasty in pseudophakia.
Applicable refractive-disorder diagnoses include H52.0–H52.7.

Denial Risk

Experimental or Investigational Refractive-Disorder Claim

CPT 65765 is experimental and investigational under the policy. When billed with a diagnosis of refractive disorder, the claim will deny as experimental and investigational.

CPT 65765 — Keratophakia.
Applicable refractive-disorder diagnoses include H52.0–H52.7.
Do not represent CPT 65765 as a covered refractive procedure.

Irregular astigmatism and corneal distortion may develop after LASIK or PRK

Limbal Deficiency

DefinitionA state caused by total loss or hypofunction of limbal epithelial stem cells

Clinical characteristicsPoor epithelialization, persistent defects or recurrent erosions, stromal inflammation and scarring, and corneal vascularization

Diagnostic featureConjunctival epithelial ingrowth onto the corneal surface

Corneal Collagen Crosslinking

DefinitionA procedure using topical riboflavin and ultraviolet irradiation to strengthen corneal collagen lamellae

PurposeTo reduce or halt progression of keratoconus or corneal ectasia

Expected effectImproved corneal rigidity through increased bonds between collagen fibers

E&I

AbbreviationE&I

MeaningExperimental and investigational

Coverage implicationEffectiveness has not been established for procedures classified as experimental and investigational

NMN

AbbreviationNMN

MeaningNot medically necessary

Coverage implicationThe service is not considered medically necessary under the applicable policy criteria