ModifiedMass General Brigham Health PlanPolicy N/A

Medical Policy Corneal Collagen Cross-linking

Defines medical necessity criteria, prior authorization requirements, covered indications, exclusions, coding guidance, and payer-specific variations for epithelium-off corneal collagen cross-linking for progressive keratoconus or corneal ectasia after refractive surgery.

Policy Summary

PayerMass General Brigham Health Plan

PolicyMedical Policy Corneal Collagen Cross-linking

Policy CodePolicy N/A

Change TypeAnnual update; prior authorization and variation additions

Effective DateOct 1, 2018

Next Review Date

Key ActionTreating specialist must request prior authorization for the procedure for applicable product lines.

SourceLink

POLICY UPDATE CHANGES

January 2026: Annual update. Updated prior authorization table and added variation for OneCare and SCO members. Fixed code disclaimer and typos.

March 2025: Summary of evidence added; references updated.

November 2024: Code table updated. Clarified Medicare Variation language. Added MassHealth Variation.

December 2022: Criteria changed under both #1 and #2 to include list of conditions.

November 2023: Medicare Advantage added to authorization table.

2Covered Indications

300 µmMinimum corneal thickness

14Minimum age

0402T, J2787Key codes (informational)

Coverage Summary

This policy covers with criteria epithelium-off corneal collagen cross-linking (CXL) to halt progression of keratoconus and corneal ectasia following refractive surgery. Effective date: 2018-10-01; Last review: 2026-01-01. Prior authorization is required and the policy addresses payer-specific variations. Covered Indications: 2.

Threshold summary

Age>= 14 years

Steepest K change>= 1.00 D increase within 24 months

Manifest cylinder change>= 1.00 D increase within 24 months

MRSE change>= 0.50 D increase within 24 months

Inferior-superior difference>= 1.5 D (for post-refractive ectasia)

Corneal thickness (thinnest point)>= 300 micrometers

Corrected distance visual acuity (CDVA)Worse than 20/20

Medical-Necessity Criteria

Coding

Primary procedure code (informational)HCPCS

0402T

Collagen cross-linking of cornea (including removal of the corneal epithelium and intraoperative pachymetry when performed)

Drug/agent code (informational)HCPCS

J2787

Riboflavin 5'-phosphate, ophthalmic solution, up to 3 mL

Alternate/other procedure code (Mass General Brigham ACO only)CPT

66999

Other procedures of the anterior segment of the eye

Provider Actions

Prior Authorization

Prior authorization required

Prior authorization is required for corneal collagen cross-linking for applicable product lines. Treating specialists must request authorization before the procedure.

Commercial
Qualified Health Plans (QHP)
Mass General Brigham ACO
Medicare Advantage
OneCare
Senior Care Options (SCO)
Codes: 0402T, J2787, 66999

Documentation Required

Documentation of progression required

Background and Evidence

Corneal collagen cross-linking (CXL) is a procedure using topical riboflavin and UV-A to strengthen corneal collagen and stabilize the cornea. This policy authorizes only the epithelium-off CXL technique, noting it is the only FDA-approved epithelium-off protocol (KXL System referenced). Criteria and indications are based on major clinical trials and evidence summarized in the policy.

Key evidence

Stabilization rate (Poli et al. 2015)89% stabilization of ectasia at 6 years

Long-term follow-up (Enders et al. 2023)Improvements can persist up to 13 years

Corneal Collagen Cross-linking: A procedure using riboflavin and ultraviolet (UV) light (epithelium-off protocol described; viscous riboflavin applied topically before and during UV irradiation using the KXL System).

Ectasia: A serious long-term complication of LASIK and PRK that is similar to keratoconus but occurs postoperatively.

Keratoconus: A bilateral dystrophy with progressive ectasia (paracentral steepening and stromal thinning) that impairs visual acuity; progression is variable and often diagnosed at a young age.

Medicare Determinations

Medicare NCD/LCD: No applicable NCD/LCD — at the most recent policy review, Medicare has no National Coverage Determination or Local Coverage Determination for corneal collagen cross-linking.

OneCare and SCO variation: Mass General Brigham follows CMS guidance where available and otherwise uses MassHealth or its own medical policies.

MassHealth variation: At the time of the policy review, MassHealth did not have medical necessity guidance for corneal collagen cross-linking.

Revision History

January 2026revisedLatest

Annual update. Updated prior authorization table and added variation for OneCare and SCO members. Fixed code disclaimer and typos.

March 2025added

Ad hoc update. Summary of evidence added; references updated.

November 2024revised

Annual update: Code table updated. Clarified Medicare Variation language. Added MassHealth Variation.

Policy Summary

PayerMass General Brigham Health Plan

PolicyMedical Policy Corneal Collagen Cross-linking

Policy CodePolicy N/A

Change TypeAnnual update; prior authorization and variation additions

Effective DateOct 1, 2018

Next Review Date

Key ActionTreating specialist must request prior authorization for the procedure for applicable product lines.

SourceLink

On This Page

Providers must document objective evidence of progression within 24 months using keratometry and corneal topography/mapping and record corneal thickness and corrected distance visual acuity (CDVA) to support medical necessity.

Increase >= 1.00 D in steepest keratometry (Kmax) or manifest cylinder within 24 months
Increase >= 0.50 D in manifest refraction spherical equivalent (MRSE) within 24 months
Inferior–superior topography difference >= 1.5 D for post-refractive ectasia
Corneal thickness (thinnest point) >= 300 micrometers
Corrected distance visual acuity worse than 20/20

Billing Rule

Epithelium-off protocol only

Authorization is limited to the epithelium-off corneal collagen cross-linking protocol; transepithelial or other non–epithelium-off protocols are not authorized under this policy.

Affected code: 0402T

Denial Risk

Claims may be denied if criteria not met

Claims may be denied if the patient does not meet all listed medical necessity criteria. Lack of required documentation or failure to meet age, progression, visual acuity, corneal thickness, or absence-of-disease requirements risks denial.

Age >= 14 years
Documented progression per thresholds (Kmax, cylinder, MRSE, or inferior–superior difference)
Corrected distance visual acuity worse than 20/20
Corneal thickness >= 300 micrometers at the thinnest point
No history of corneal or systemic disease that would interfere with healing

November 2023added

Annual update: Medicare Advantage added to authorization table.

December 2022revised

Annual update: Criteria changed under both #1 and #2 to include list of conditions.