CurrentKaiser PermanentePolicy N/A

Clinical Review Criteria — Corneal Procedures for Correction of Refractive Errors (PTK, LASIK/PRK)

Clinical review criteria governing medical necessity and coverage for corneal procedures to correct refractive errors and to treat corneal disease for Kaiser Foundation Health Plan of Washington members; intended for providers evaluating authorization and coverage for PTK, LASIK/PRK and related corneal procedures.

Policy Summary

PayerKaiser Permanente

PolicyCorneal Procedures for Correction of Refractive Errors (PTK, LASIK/PRK) — Clinical Review Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and document pre- and postoperative refractions showing ≥2.5 D increase in astigmatism/anisometropia with attempts at non-surgical correction before approval.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Covered when criteria metPTK coverage

Not coveredPRK coverage

≥2.5 DRequired refractive change

≥250 μmMin corneal thickness

CPT/HCPCS listProcedure codes

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Coverage Criteria

Correction of surgically induced refractive errors

Covered when ALL of the following conditions are met:

Refractive correction coverage criteria: 1) Astigmatism and/or anisometropia have been surgically induced; 2) Patient is unable to wear glasses or contact lenses after surgery due to anisometropia and/or high astigmatism; 3) There is a >= 2.5 diopter increase in astigmatism and/or anisometropia from the preoperative to postoperative state; 4) Documented attempts to correct the surgical error with historical means of refraction and/or contact lens fitting; 5) Patient reports functional disability from the increased astigmatism and the surgeon reasonably expects laser will improve function; 6) Equipment used is FDA-approved and the procedure is performed by an ophthalmologist trained to use it; 7) The patient's primary problem is not corneal rejection or multiple graft failures where comfort, not vision improvement, is the goal.

PTK for corneal disease

Covered when ALL of the following are met and ONE of the stated uses is present:

PTK coverage general: 1) Used to remove damaged and/or diseased tissue from the anterior surface of the cornea, to treat anterior corneal dystrophies, remove scars and opacities in the anterior third of the cornea, or smooth irregular corneal surfaces to improve visual acuity, reduce pain, or improve spectacle/contact lens tolerance; 2) The proposed treatment area is up to 300 microns thick or the cornea will be at least 250 microns thick after ablation, and other less invasive treatments have failed or are not possible (e.g., stromal puncture); 3) None of the absolute exclusion conditions exist (see exclusions).

Coverage exclusions: PTK and related corneal laser procedures are not covered when any of the following conditions are present: active corneal infection, bullous keratopathy, depressed scars, or pathology that extends beyond the anterior third of the cornea. Requests are also excluded for eyes with unstable keratometry or existing hyperopia. Additional relative contraindications that commonly warrant exclusion include poorly controlled autoimmune disease, use of immunosuppressive medications, keratoconus and other corneal ectasias, coexisting ocular disease, a history of keloid formation, and underlying systemic disease affecting wound healing.

Operational note for reviewers: these exclusion conditions must be absent for PTK to be considered. If any exclusion or relative contraindication above is documented, the procedure should generally be denied or deferred until the condition is resolved or appropriately managed.

Photorefractive keratectomy (PRK) for the correction of refractive errors in otherwise non-diseased corneas is considered cosmetic and not medically necessary. Historical guidance and internal review concluded that PRK (the excimer laser application for refractive correction) is a non-covered service except in limited circumstances; therefore requests solely for refractive correction in healthy corneas should be denied as cosmetic.

When evaluating requests, distinguish PRK from PTK: although technically similar, PTK is intended to treat anterior corneal disease (and may be covered when criteria are met), whereas PRK is directed at refractive correction and is not covered per policy.

Coding and Clinical Thresholds

Considered Medically Necessary when criteria metCPT | HCPCSCovered

65765	Keratophakia
65767	Epikeratoplasty
65771	Radial keratotomy
65772	Corneal relaxing incision for correction of surgically-induced astigmatism
65775	Corneal wedge resection for correction of surgically induced astigmatism
65760	Keratomileusis
S0800	Unspecified (listed as applicable)
S0812	Phototherapeutic keratectomy (PTK)

Considered Cosmetic & Not Medically NecessaryHCPCSNot Covered

S0810

Photorefractive keratectomy (PRK)

inv-07: Required increase in astigmatism/anisometropia for refractive correction coverage

Required magnitude>= 2.5 diopters increase in astigmatism and/or anisometropia from pre- to postoperative state

Clinical contextChange must be surgically induced and associated with inability to wear glasses or contact lenses after surgery

Documentation neededPre- and postoperative refractions demonstrating the >=2.5 D increase and documented attempts at correction with refraction/contact lens fitting

inv-08: Post-ablation corneal thickness minimum requirement

Minimum residual corneal thicknessCornea must be at least 250 microns thick after ablation

Treatment area limit

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for PTK and related corneal procedures. Verify authorization requirements for specific CPT/HCPCS codes by plan type using the Pre-authorization Code Check prior to scheduling or billing.

Verify prior authorization via the Pre-authorization Code Check for member's plan type before performing PTK or related procedures
PTK-related covered CPT/HCPCS examples: 65765, 65767, 65771, 65772, 65775, 65760, S0800, S0812
Photorefractive keratectomy (PRK) code example considered cosmetic and not covered: S0810
Codes listed may not be all-inclusive; deleted or out-of-effect codes may not be covered

Background

Background: The excimer 193 nm laser is the technology used to perform both phototherapeutic keratectomy (PTK) and photorefractive keratectomy (PRK). PTK uses the excimer laser to remove diseased or damaged tissue from the anterior corneal surface to treat corneal pathology, scars, dystrophies, or irregularities, whereas PRK uses the laser to ablate corneal tissue to correct refractive errors (myopia, hyperopia, astigmatism) in otherwise non-diseased corneas.

Clinical context and historical policy position: Internal review (COMET, 1996) found the excimer 193 nm laser effective for both PTK and PRK but recommended that PTK for corneal pathology be covered when criteria are met, while PRK for routine refractive correction be treated as a non-covered, cosmetic service. The policy distinguishes the two indications and limits PTK coverage to cases where corneal disease or functional intolerance to lenses/spectacles is documented and other less invasive treatments have failed or are not possible.

Definitions

inv-14: Definition — Anisometropia

DefinitionEyes having unequal refractive power

Relevance to coverageAnisometropia that is surgically induced and causes inability to wear corrective lenses may qualify for corrective corneal procedures

Measurement contextChange in anisometropia measured by comparison of pre- and postoperative refractions

inv-15: Definition — Phototherapeutic keratectomy (PTK)

DefinitionExcimer laser procedure used to remove diseased or damaged tissue from the anterior cornea to treat corneal pathology, scars, dystrophies, or irregularities

IndicationsUsed to improve visual acuity, reduce pain, or improve tolerance of spectacles/contact lenses when anterior corneal disease is present