Keratoplasty (corneal transplant)
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Medical necessity criteria and coding guidance for corneal transplant procedures (keratoplasty) for members of Peach State Health Plan/affiliated Centene health plans. Applies to providers requesting coverage for corneal transplant procedures.
No material clinical or coverage changes in this revision.
Coverage / Medical Necessity Criteria
Medically Necessary Indications
Keratoplasty is medically necessary for the following indications:
Medically necessary indications
- Indications list: Infectious corneal ulcers; Keratoconus; Bullous keratopathy; Previous failed grafts; Central corneal scars; Corneal dystrophies; Pellucid marginal degeneration; Descemetocele at risk of perforation; Corneal ectasia after LASIK; Corneal fibrosis
Any single indication from this list meets the stated medical necessity criteria per the policy.
The policy references specific Current Procedural Terminology (CPT) codes for keratoplasty (including 65730, 65750, 65755, 65756, and 65757) for informational purposes, but inclusion or exclusion of any CPT code in this clinical policy does not guarantee coverage. Providers must reference the plan's coverage determinations, benefit contract terms, and the most up-to-date professional coding guidance prior to claim submission and authorization requests.
This policy does not state any explicit technique- or procedure-level exclusions declaring specific keratoplasty approaches as 'not medically necessary.' Coverage determinations are based on the listed medically necessary indications and the member's applicable benefit terms; the policy is intended as a guide to medical necessity rather than a guarantee of payment.
Procedure and Diagnosis Coding
| 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 prior to transplantation (List separately in addition to code for primary procedure). |
| H18.11 | Bullous keratopathy, right eye. |
| H18.12 | Bullous keratopathy, left eye. |
| H18.13 | Bullous keratopathy, bilateral. |
| H18.611 | Keratoconus, stable, right eye. |
| H18.612 | Keratoconus, stable, left eye. |
| H18.613 | Keratoconus, stable, bilateral. |
| H18.621 | Keratoconus, unstable, right eye. |
| H18.622 | Keratoconus, unstable, left eye. |
| H18.623 | Keratoconus, unstable, bilateral. |
| H18.711 | Corneal ectasia, right eye. |
| T85.318A | Breakdown (mechanical) of other ocular prosthetic devices, implants and grafts, initial encounter. |
| T85.318D | Breakdown (mechanical) of other ocular prosthetic devices, implants and grafts, subsequent encounter. |
| T85.318S | Breakdown (mechanical) of other ocular prosthetic devices, implants and grafts, sequela. |
| T85.328A | Displacement of other ocular prosthetic devices, implants and grafts, initial encounter. |
| T85.328D | Displacement of other ocular prosthetic devices, implants and grafts, subsequent encounter. |
| T85.328S | Displacement of other ocular prosthetic devices, implants and grafts, sequela. |
| T86.8401 | Corneal transplant rejection, right eye. |
| T86.8402 | Corneal transplant rejection, left eye. |
| T86.8403 | Corneal transplant rejection, bilateral. |
| T86.8411 | Corneal transplant failure, right eye. |
Provider Requirements and Operational Guidance
Prior authorization required for listed keratoplasty CPT codes
Keratoplasty procedures listed in this policy (CPT 65730, 65750, 65755, 65756, 65757) require prior authorization per the plan's usual processes when requesting coverage for corneal transplant procedures.
- CPT 65730 — Keratoplasty (corneal transplant); penetrating (except in aphakia or pseudophakia).
- CPT 65750 — Keratoplasty (corneal transplant); penetrating (in aphakia).
- CPT 65755 — Keratoplasty (corneal transplant); penetrating (in pseudophakia).
- CPT 65756 — Keratoplasty (corneal transplant); endothelial.
- CPT 65757 — Backbench preparation of corneal endothelial allograft prior to transplantation (List separately in addition to code for primary procedure).
No step-therapy sequencing required before keratoplasty
The policy does not impose step therapy or a required sequence of conservative treatments before keratoplasty; clinical background describes alternative surgical techniques and medical management options but does not mandate sequencing.
- Clinical alternatives discussed include DSEK/DSAEK/DMEK (endothelial procedures) and DALK (deep anterior lamellar keratoplasty).
- Medical management of graft rejection (topical/oral corticosteroids, subconjunctival or sub-Tenon's injections) is described but not required as a prior step to surgery.
Document postoperative exams, suture management, and graft rejection monitoring
Postoperative clinical documentation is expected to include slit-lamp biomicroscopic examinations to assess corneal clarity and graft health, monitoring for suture erosion and timing of selective suture removal, and documentation of signs or symptoms of graft rejection and their management.
- Perform and document slit-lamp biomicroscopic exams to assess corneal clarity, graft status, and suture condition.
- Document selective suture removal decisions (typically beginning after three months) guided by topography and wound stability, and note any earlier removal for loose sutures or suture erosion.
- Document patient counseling on rejection warning signs (redness, photophobia, vision change, pain) and any therapeutic interventions for rejection (topical/oral corticosteroids; subconjunctival or sub‑Tenon's injections).
Coding/capture risk — codes in policy are informational only
Inclusion or exclusion of CPT codes in this policy does not guarantee coverage; providers must reference current coding guidance before claim submission and recognize that listed codes are informational.
- Codes in the policy are provided for informational purposes only and are not all‑inclusive.
- Providers should consult the most up-to-date professional coding sources prior to submission of reimbursement claims.
Clinical Background
Keratoplasty (corneal transplant) is a surgical procedure that replaces diseased or damaged corneal tissue with donor tissue to restore or preserve vision. Multiple techniques exist to address different layers and causes of corneal disease, including full‑thickness penetrating keratoplasty (PK), lamellar approaches such as DALK (deep anterior lamellar keratoplasty) when the endothelium is healthy, and endothelial procedures such as DSEK/DSAEK and DMEK that replace only the posterior corneal layers. Endothelial techniques are frequently preferred for primary endothelial disorders because they preserve corneal structure and often have superior visual outcomes and lower rejection risk compared with full‑thickness grafts; DALK reduces endothelial rejection risk for stromal disease but may have interface opacity risks. Postoperative management and documentation (for example, slit‑lamp examinations, suture management, and surveillance for rejection) are integral to patient care and to supporting coverage and ongoing treatment decisions.
Procedure Definitions and Techniques
Revision History
Original approval of the Keratoplasty clinical policy (CP.VP.36).
Policy converted to new template.
Annual review with added ICD-10 diagnosis codes.
Annual review performed.
Policy approval following annual review.
Annual review performed.
Policy approval following annual review.
Annual review performed.
Policy approval following annual review.
Annual review with updated references.
Policy approval following annual review and reference updates.
Annual review performed; Last Review Date recorded as 08/2025.
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