Corneal Collagen Cross-linking for Treatment of Keratoconus
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Policy governing coverage and prior authorization requirements for corneal collagen cross-linking (CXL) to treat progressive keratoconus or corneal ectasia after refractive surgery for Moda Health members and providers.
No material clinical or coverage changes in this revision.
Coverage Criteria for Corneal Collagen Cross-Linking
Covered Criteria
Covered when ALL of the following are met
Epithelium-on (transepithelial) corneal collagen cross-linking (CXL) is explicitly excluded by this policy and is considered experimental and investigational for all indications. Requests for CXL using a transepithelial technique will not meet the coverage criteria described in this policy.
CXL is considered not medically necessary/experimental when requested for any indication other than progressive keratoconus or corneal keratectasia following refractive surgery. Requests for CXL outside those diagnoses will be denied.
Relevant Procedure and Diagnosis Codes
| H18.60 | Keratoconus, unspecified |
| 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 |
| H18.62 | Keratoconus, unstable |
Provider Requirements, Authorization, and Documentation
Prior Authorization Required
Prior authorization is required before performing corneal collagen cross-linking; submit a prior authorization request that includes chart notes documenting the diagnosis and a description of the procedure. The covered procedure is epithelium-off photochemical collagen cross-linkage using riboflavin (J2787) and ultraviolet A (CPT 0402T listed in coding).
Step Therapy / Conservative Management Notes
Document that conservative management options were considered and discussed with the patient prior to CXL; the policy describes spectacles, rigid gas-permeable contact lenses, intrastromal corneal ring segments, and keratoplasty as alternative or prior options. The policy does not mandate a specific stepwise sequence, but discussion/documentation of these options should be present.
- Discuss spectacle correction and rigid gas-permeable contact lens use and intolerance if applicable.
- Document consideration of intrastromal corneal ring segments and keratoplasty where relevant.
- No specific step-therapy sequence is mandated by the policy.
Required Documentation for PA
Include chart notes with (1) the clinical diagnosis, (2) a description of the procedure to be performed, and (3) the specific type of collagen cross-link technique planned (epithelium-off with riboflavin/J2787 and UVA).
- Diagnosis: progressive keratoconus or corneal ectasia following refractive surgery.
- Procedure description: planned epithelium-off photochemical collagen cross-linkage.
- Medication/agent: riboflavin ophthalmic solution (J2787) and use of UVA.
Denial Risk — Experimental/Non-covered Indications
Requests for epithelium-on (transepithelial) CXL or for any indications other than progressive keratoconus or corneal ectasia after refractive surgery are considered experimental/investigational and will be denied.
- Epithelium-on (transepithelial) collagen cross-linking is explicitly considered experimental and investigational.
- CXL for indications other than progressive keratoconus or post-refractive surgery ectasia is experimental/investigational and not covered.
Definitions
Background
Keratoconus is a progressive, noninflammatory thinning and cone-shaped protrusion of the cornea that can cause visual impairment. Corneal collagen cross-linking (CXL) is a photochemical procedure that uses riboflavin ophthalmic solution in combination with ultraviolet A light to strengthen corneal collagen and slow disease progression. This policy covers epithelium-off photochemical CXL performed with riboflavin (HCPCS J2787) and UVA for members with progressive keratoconus or corneal keratectasia following refractive surgery; other techniques and indications are considered experimental/investigational and are not covered.
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