Modifiedpriority healthPolicy 91529-R5

REFRACTIVE KERATOPLASTY / LASIK

Defines medical necessity, limitations, and applicable coverage rules for refractive keratoplasty procedures (including PTK, INTACS) and lists procedures considered not medically necessary such as LASIK and PRK; applies to Priority Health insured products and Medicaid in Michigan.

Policy Summary

Payerpriority health

PolicyREFRACTIVE KERATOPLASTY / LASIK

Policy CodePolicy 91529-R5

Change TypeRestructured criteriaadded governmental regulationsenhanced description

Effective DateSep 1, 2025

Next Review DateAug 25, 2025

Key ActionSubmit prior authorization with documentation showing the procedure meets the policy's medical necessity criteria when required.

SourceLink

POLICY UPDATE CHANGES

Added Section II. GOVERNMENTAL REGULATIONS.

Restructured Section I. POLICY/CRITERIA to include specific inclusions and limitations/exclusions sections.

Enhanced Description section.

6+PTK indications enumerated

>=3.00Astigmatism threshold (D)

36 / 60Post-surgical timing (months)

MultipleProcedures excluded

HMO/PPO/Medicaid

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria

Medically Necessary Procedures

Covered when ALL of the following sets apply as specified below

PTK indications: Phototherapeutic keratectomy (PTK) is medically necessary when used to treat specific corneal lesions, to remove scar tissue from the visual field, or to address an abnormality of the eye. Specific indications include: superficial corneal dystrophy (including granular, lattice, and Reis-Buckler's dystrophy); epithelial membrane dystrophy; irregular corneal surfaces due to Salzmann's nodular degeneration or keratoconus nodules; corneal scars and opacities (post‑traumatic, post‑infectious, post‑surgical, or secondary to pathology); and recurrent corneal erosions after failure of conservative measures such as lubricants, hypertonic saline, patching, bandage contact lenses, or gentle debridement of severely aberrant epithelium.

Conservative measures must have failed for recurrent corneal erosions

Post-surgical corneal relaxing incision/wedge resection

Temporal criterion (one required): Member had previous penetrating keratoplasty (corneal transplant) within the past 60 months OR member had cataract surgery within the last 36 months.
Required clinical findings (both required): Degree of astigmatism is 3.00 diopters or greater AND member is intolerant of glasses or contact lenses.>= 3.00 diopters

INTACS for keratoconus/pellucid: Intrastromal corneal ring segments (INTACS, CPT 65785) are medically necessary for reduction or elimination of myopia or astigmatism in persons with keratoconus or pellucid marginal degeneration who can no longer achieve adequate vision with contact lenses or spectacles and for whom corneal transplant is the only remaining option.

Covered Indications for Intrastromal Corneal Ring Segments

Covered when ALL of the following are met for implantation of intrastromal corneal ring segments (CPT 65785):

Coverage conditions for CPT 65785

Acceptable diagnoses (one required): Keratoconus (unstable or codes in H18.601–H18.619), unspecified corneal degeneration, or other congenital malformations of the cornea.
Refer to ICD-10 code group for full list.
Clinical eligibility: Member can no longer achieve adequate vision with contact lenses or spectacles AND corneal transplant is the only remaining option.

Coding and prior authorization note: Use CPT 65785 for implantation of intrastromal corneal ring segments when above criteria are met; prior authorization and supporting documentation (diagnosis codes and clinical justification) may be required.

See coding section for applicable CPT and ICD-10 codes and prior authorization requirements.

Refractive surgical procedures performed solely to correct myopia, hyperopia, astigmatism, or presbyopia are considered not medically necessary. These cosmetic/refractive procedures are excluded from coverage when their only purpose is refractive correction.

Phototherapeutic keratectomy (PTK) for the treatment of infectious keratitis is considered experimental and investigational and therefore not medically necessary.

PTK performed in combination with corneal collagen cross-linking is considered experimental and investigational and is not medically necessary. (Note: collagen cross-linking is described in CPT/HCPCS listings but combination with PTK remains excluded.)

The following procedures are not covered: CPT 65760 (Keratomileusis); 65765 (Keratophakia); 65767 (Epikeratoplasty); 65771 (Radial keratotomy); S0800 (LASIK); and S0810 (PRK). Claims for these procedures billed with routine refractive diagnosis codes (e.g., H52.xx or Z01.00–Z01.01) do not support medical necessity. For unlisted anterior segment procedures (CPT 66999) include explanatory documentation with the claim as required.

Elective keratorefractive procedures intended for cosmetic correction of refractive error — including but not limited to LASIK (S0800), PRK (S0810), LASEK, RK, LTK, phakic IOL implantation, CLE, intracorneal inlays, ALK, hexagonal keratotomy, CK, and mini-RK — are considered not medically necessary and will be denied when performed solely to correct refractive errors.

Procedures performed solely to correct refractive errors without qualifying corneal diagnoses (for example, simple myopia, hyperopia, astigmatism, or presbyopia coded in the H52.xx series or routine vision encounter codes Z01.00–Z01.01) are excluded from coverage. Such claims do not meet medical necessity criteria and will be denied as cosmetic/refractive.

Coding

Coding references and applicabilitymixed

No codes listed

CPT/HCPCS codes listed with notesCPT

0402T	Collagen cross-linking of cornea (including removal of the corneal epithelium and intraoperative pachymetry when performed)
65770	Keratoprosthesis
65772	Corneal relaxing incision for correction of surgically induced astigmatism
65775	Corneal wedge resection for correction of surgically induced astigmatism
S0812	Phototherapeutic keratectomy (PTK)
66999	Unlisted procedure, anterior segment of eye

Covered CPT Codes (when criteria met)CPTCovered

65785

Implantation of intrastromal corneal ring segments

CPT/HCPCS Codes Not CoveredCPTNot Covered

65760	Keratomileusis
65765	Keratophakia
65767	Epikeratoplasty
65771	Radial keratotomy
S0800	Laser in situ keratomileusis (LASIK)
S0810	Photorefractive keratectomy (PRK)

ICD-10 Codes that may support medical necessityICD-10

H17.9	Unspecified corneal scar and opacity
H17.89	Other corneal scars and opacities
H18.601	Keratoconus, unspecified
H18.611	Keratoconus, stable
H18.621	Keratoconus, unstable
H18.40	Unspecified corneal degeneration
Q13.4	Other congenital malformations of cornea

ICD-10 Codes that do NOT support medical necessity for proceduresICD-10Not Covered

H52.00	Hypermetropia (series H52.00-H52.03 and other H52.xx listed)
H52.10	Myopia (H52.10-H52.13)
H52.4	Presbyopia
Z01.00	Encounter for examination of eyes and vision

Astigmatism threshold — >= 3.00 diopters

Astigmatism threshold>= 3.00 diopters

Measurement basisDegree of astigmatism must be 3.00 D or greater as documented on refraction/topography

Requirement linkUsed with temporal and intolerance criteria for coverage of corneal relaxing incision/wedge resection

Post-penetrating keratoplasty timeframe — within the past 60 months

Timeframe since penetrating keratoplastyWithin the past 60 months

Context

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization may be required for certain services, drugs, and procedures. When prior authorization is required, the provider must submit documentation demonstrating medical necessity per the policy and Priority Health Provider Manual.

Submit prior authorization requests with complete clinical documentation supporting the applicable medical necessity criteria in the policy.
Prior authorization status and requirements may vary by product (e.g., Medicare, Medicaid) — verify via the Provider Manual.

Documentation Required

Documentation and Medical Necessity Requirements

Providers must submit documentation that demonstrates medical necessity when prior authorization is requested or when billed services are subject to review. Documentation should specifically address the clinical criteria listed in the policy (for example: diagnosis, prior conservative treatments, intolerance of corrective lenses, degree of astigmatism, transplantation status, prior surgeries, and trial of contact lenses when applicable).

Background

Refractive errors occur when the eye does not focus light on the retina, producing myopia, hyperopia, astigmatism, or presbyopia. Keratorefractive surgeries alter corneal shape to change refractive power. Phototherapeutic keratectomy (PTK) is distinct from photorefractive keratectomy (PRK): PTK treats specific corneal disease and removes pathologic superficial tissue (for example, dystrophies or scar) rather than being performed solely to correct refractive error. LASIK has been the most commonly performed keratorefractive procedure since it became widely used, but many listed procedures are considered cosmetic and are not covered when performed for refractive purposes.

Definitions

Photorefractive Keratectomy (PRK) — definition/description

DefinitionSurface ablation laser eye surgery where the corneal epithelium is removed and an excimer laser reshapes the underlying corneal stroma.

Key pointsNo corneal flap is created; longer recovery than LASIK; suitable for patients with thinner corneas.

DistinctionPRK treats refractive errors and is distinct from PTK, which treats corneal disease.

LASIK — definition/description

DefinitionLaser-assisted procedure where a corneal flap is created, the underlying stroma is reshaped with an excimer laser, and the flap is repositioned.

Key pointsFaster visual recovery than PRK; risk of flap-related complications.

Policy Summary

Payerpriority health

PolicyREFRACTIVE KERATOPLASTY / LASIK

Policy CodePolicy 91529-R5

Change TypeRestructured criteriaadded governmental regulationsenhanced description

Effective DateSep 1, 2025

Next Review DateAug 25, 2025

Key ActionSubmit prior authorization with documentation showing the procedure meets the policy's medical necessity criteria when required.

SourceLink

On This Page

One temporal criterion required for coverage of surgically induced astigmatism correction

DocumentationHistory of prior penetrating keratoplasty must be documented in the medical record

Post-cataract surgery timeframe — within the last 36 months

Timeframe since cataract surgeryWithin the last 36 months

ContextOne temporal criterion required for coverage of surgically induced astigmatism correction

DocumentationRecord of prior cataract surgery and dates must be provided to support eligibility

Include relevant ICD-10 codes that support medical necessity (see policy coding list).
For intrastromal corneal ring segments (CPT 65785) include documentation that member is no longer able to achieve adequate vision with contact lenses or spectacles and that corneal transplant is the only remaining option.

Billing Rule

Explanatory Notes Required for Unlisted Anterior Segment Procedures (CPT 66999)

Claims for an unlisted anterior segment procedure (CPT 66999) must be accompanied by explanatory notes describing the procedure performed and clinical rationale to support medical necessity.

Attach operative report and clinical notes explaining why a listed CPT code did not apply.
Include pre- and post-operative findings and relevant diagnostic codes.

Prior Authorization

Conservative Treatment Required Before PTK

Phototherapeutic keratectomy (PTK) for recurrent corneal erosions and similar indications should only be considered after conservative treatments have failed.

Document trial and failure of conservative therapies prior to PTK (e.g., lubricants, hypertonic saline, patching, bandage contact lenses, gentle debridement).
PTK is indicated when conservative measures have not halted recurrent erosions or when treating specified corneal dystrophies, scars, or irregular surfaces per policy inclusions.

Denial Risk

Denial Risk for Routine Refractive Diagnoses

Claims billed with routine refractive diagnosis codes will not meet medical necessity and are at high risk for denial. Procedures performed solely to correct refractive errors are considered cosmetic and not medically necessary.

Do NOT bill keratoplasty, PTK, INTACS or other corneal procedures with routine refractive ICD-10 codes (e.g., H52.xx, Z01.00-Z01.01).
If the procedure addresses a corneal abnormality (scarring, dystrophy, recurrent erosion, surgically induced astigmatism, etc.), include supporting corneal-specific diagnosis codes from the policy coding list (e.g., H17.x, H18.x, Z94.7).

Clinical roleCommonly performed keratorefractive surgery to correct refractive errors in otherwise nondiseased corneas.

Phototherapeutic Keratectomy (PTK) — definition/description

DefinitionSurgical laser procedure used to treat specific corneal diseases by removing pathologic superficial tissue such as dystrophies or scars (distinct from PRK).

IndicationsUsed for superficial corneal dystrophy, epithelial membrane dystrophy, Salzmann's nodular degeneration, corneal scars/opacities, and recurrent corneal erosions when conservative measures have failed.

DistinctionPTK addresses corneal disease rather than elective refractive correction.

Clear Lens Extraction (CLE) / Phakic IOL — definition/description

DefinitionRemoval of the eye's natural lens (even if clear) and replacement with an intraocular lens (IOL), similar to cataract surgery.

Key pointsUsed for very high refractive errors or presbyopia; eliminates accommodation.

Clinical noteConsidered a refractive procedure when performed solely to correct refractive error and is listed among procedures not medically necessary for elective refractive indications.

Intracorneal Inlays — definition/description

DefinitionSmall devices implanted into the corneal stroma to improve near vision, typically for presbyopia.

Key pointsPreserve distance vision and can be removed if needed.

Clinical noteListed among procedures considered not medically necessary when performed solely for refractive/cosmetic indications.

Automated Lamellar Keratoplasty (ALK) — definition/description

DefinitionMechanical microkeratome creates a corneal flap and removes a disc of stromal tissue to reshape the cornea.

Key pointsPrecursor to LASIK; less precise than laser-based methods.

Historical noteConsidered an older technique and is included among procedures generally not medically necessary for elective refractive purposes.

Other historical procedures — brief descriptions (hexagonal keratotomy, CK, mini-RK)

Hexagonal keratotomyVariation of radial keratotomy using hexagonal incisions to flatten the central cornea; rarely used today and associated with unpredictable outcomes.

Conductive keratoplasty (CK)Uses radiofrequency energy to shrink peripheral corneal collagen to steepen the central cornea; provides temporary correction for hyperopia or presbyopia.

Minimally invasive radial keratotomy (mini-RK)Modified RK technique using fewer and shallower incisions aimed at reducing complications of traditional RK; largely outdated.