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    v1.0.28
    OpenPayerPolicy UpdatesOphthalmology/OptometrySelectHealth autologous serum eye drops Coverage U…
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    ModifiedSelectHealthPolicy N/A

    Autologous Serum Eye Drops (Ophthalmology/Optometry Coverage Criteria)

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    This policy defines SelectHealth's coverage stance for autologous serum eye drops for dry eye and related ocular surface disorders across Commercial, Medicare, and Medicaid lines of business.

    Policy Summary
    PayerSelectHealth
    PolicyAutologous Serum Eye Drops (coverage criteria)
    Policy CodePolicy N/A
    Change TypeMaterial criteria modifications and device additions
    Effective DateNov 14, 2023
    Last ReviewDec 1, 2024
    Next Review DateDec 1, 2024
    Key ActionObtain prior authorization with taped and untaped automated visual field testing and required photos/documentation to demonstrate functional impairment when seeking coverage.
    SourceLink
    POLICY UPDATE CHANGES

    Modified criteria to require automated peripheral or superior visual field testing, with the eyelids taped and untaped, showing improvement of 30% or 12 degrees in the number of points seen on the tape testing for Commercial Plan Policy.

    For Commercial Plan Policy, added coverage criteria for iStent infinite device.

    For Commercial Plan Policy, simplified requirement in criterion #C-3 to: 'Patient is currently using at least one eyedrop for control.'

    For Commercial Plan Policy, added coverage criteria for iStent infinite device.

    For Commercial Plan Policy, simplified requirement in criterion #C-3 to: 'Patient is currently using at least one eyedrop for control.'

    Not coveredCommercial/CHIP stance
    30% / 12°
    Field improvement threshold
    ≤2 mmMRD1 threshold
    68899Unlisted code
    20%–100%Preparation range

    Coverage Criteria and Medical Necessity

    Coverage summary by product

    Coverage determinations vary by product line:

    Commercial/CHIP Coverage Stance: Select Health does NOT cover autologous serum eye drops as it is considered experimental/investigational.

    Direct statement of noncoverage for Commercial and CHIP plans.

    Medicare (CMS): Coverage is determined by CMS; if CMS has not adopted a determination and InterQual criteria are not available, the Select Health Commercial policy applies.

    Providers should consult the CMS Medicare Coverage Database for current determinations.

    Medicaid (Select Health Community Care): Select Health Community Care policies typically align with State of Utah Medicaid policy and may use InterQual; there may be situations where NCD/LCD or Select Health commercial policies are used.

    Providers should consult Utah Medicaid resources for current state-level determinations.

    Initial Upper Lid Blepharoplasty/Blepharoptosis Repair

    Covered when ANY of the following are met for the affected eye:

    Upper Lid Repair Criteria

    • B - Reconstructive criteria: a) Functional/physical impairment complaint directly related to eyelid position; b) Automated peripheral or superior visual field testing, with eyelids taped and untaped, showing improvement of 30% or 12 degrees in number of points seen (manual testing accepted if computerized testing unavailable); c) Frontal or lateral photographs consistent with visual field limitation; d) Any related disease process (e.g., myasthenia gravis, thyroid) documented as stable.30% or 12 degrees

      If visual field testing is not possible, see policy section 'When Patient is Not Capable of Visual Field Testing'.

    Brow Ptosis Repair

    Brow ptosis repair is medically necessary for reconstructive purposes when ALL of the following are present in the affected eye:

    Brow Ptosis Criteria: a) Functional/physical impairment complaint directly related to eyelid/brow position; b) Photographs demonstrate the eyebrow is below the supraorbital rim; c) Automated peripheral or superior visual field testing, with the eyelids taped and untaped, showing improvement of 30% or 12 degrees in number of points seen (manual testing accepted if computerized testing unavailable); d) Frontal or lateral photographs demonstrate field limitation consistent with testing; e) Any related disease process documented as stable.30% or 12 degrees

    If visual field testing is not possible, see policy section 'When Patient is Not Capable of Visual Field Testing'.

    Lower Lid Blepharoplasty

    Lower lid blepharoplasty is usually cosmetic but considered reconstructive and medically necessary only when ALL the following are present:

    Lower Lid Criteria: a) Color photograph documents the pathology; AND b) One of the following: facial nerve damage; inability to close the eye due to lower lid dysfunction; OR functional impairment defined by BOTH documented uncontrolled tearing or irritation AND conservative treatments tried and failed.

    Conservative treatments should be documented as attempted and failed prior to surgery unless acute severe pathology is present.

    Canthoplasty / Canthopexy

    Covered when ALL the following are present:

    Canthoplasty/Canthopexy Criteria: a) Functional impairment attributable to the canthal/lid abnormality; b) Conservative treatments have been tried and failed; c) Color photograph documents the pathology; d) Simple ectropion/entropion repair will not correct the condition; and e) At least one patient complaint such as epiphora not resolved by conservative measures, corneal dryness unresponsive to lubricants, or corneal ulcer.

    Document conservative management attempts and photographic evidence.

    Lid Retraction Surgery

    Covered when ALL the following are present:

    Lid Retraction Criteria: a) Other causes for lid retraction have been eliminated (e.g., pharmacologic dilation, glaucoma medications); b) Color photograph documents the pathology; c) Functional impairment (dry eyes, pain/discomfort, tearing, blurred vision) is present; d) Conservative treatments have been tried and failed; e) In thyroid eye disease, two or more Hertel measurements at least six months apart with the same base are unchanged.

    Document elimination of reversible causes and conservative therapy trials.

    Eyelid surgery for anophthalmic socket

    Considered reconstructive and medically necessary when BOTH are present:

    Anophthalmic Socket Criteria: a) Patient has an anophthalmic condition (no eyeball); b) Patient is experiencing difficulties fitting or wearing an ocular prosthesis.

    Photographic documentation and clinical notes regarding prosthesis fit should be provided.

    Functional Indications for Ptosis and Blepharoplasty

    Covered when ALL of the following are met (functional indications supported by literature):

    Functional Indications: Patient has quantitative or qualitative functional impairment from upper eyelid position or ptosis evidenced by at least one of the listed measures: MRD1 ≤ 2 mm in primary gaze; superior visual field loss ≥ 12 degrees (≈24%); downgaze MRD1 ≤ 2 mm impairing reading; or self-reported functional impairment interfering with activities or occupational duties.see thresholds

    AAO/OTA literature supports these thresholds as functionally significant; photographic and visual field documentation recommended.

    Conservative Management and Surgical Indications

    Surgical management may be considered after conservative therapy when applicable:

    Conditions requiring prior conservative management: For ectropion, entropion, and blepharospasm, conservative measures (artificial tears, ointments, taping, temporary tarsorrhaphy, botulinum toxin for blepharospasm) should be attempted and documented unless severe anatomical findings (e.g., corneal breakdown) warrant immediate surgery.

    Document trials of conservative measures and response; exceptions permitted for urgent corneal compromise.

    Commercial/CHIP Coverage Criteria

    Covered when ALL of the following are met

    Commercial/CHIP coverage: 1) Patient has a diagnosis of keratoconus or corneal ectasia; 2) The medicine/device used is Photrexa Viscous/Photrexa with the KXL device; 3) Procedure is epithelium-off corneal crosslinking; 4) Limit once per lifetime, per eye.

    Applies to Select Health Commercial and CHIP plans; corneal crosslinking in conjunction with INTACS is not covered.

    Corneal epithelial or limbal stem cell transplant — coverage statement

    Covered when the following are met:

    Covered Indications: Transplant using autograft, allograft, or tissue-cultured limbal/amnion-derived epithelial cells to repopulate corneal epithelial stem cells and support corneal surface reconstruction.

    Coverage depends on individual benefit plan; documentation should support indication and graft source.

    Coverage Statements

    Coverage stances as stated by Select Health for the services in this section

    Corneal epithelial or limbal stem cell transplant coverage: Select Health covers corneal epithelial or limbal stem cell transplants using autograft, allograft, or tissue-cultured sources including human amniotic epithelial cells when member benefits include this coverage.

    Providers must verify member benefits and may require prior authorization.

    Tissue culturing methods status: Tissue culturing/expansion methods are promising but unproven due to heterogeneity of techniques and lack of controlled trials; outcomes vary across case series.

    Select Health characterizes these methods as requiring further validation.

    Corneal hysteresis testing stance: Select Health does NOT cover corneal hysteresis testing for commercial plan members because it is considered experimental/investigational.

    Although devices such as the Reichert ORA have 510(k) clearance, Select Health deems CH testing investigational for coverage.

    Evidence summary / coverage stance

    Evidence summary: Peer-reviewed studies show associations between corneal hysteresis and glaucoma-related measures, but evidence does not establish that CH measurement improves patient management or outcomes; inter- and intra-machine reliability and clinical application remain unresolved.

    Select Health cites observational and prospective studies and concludes insufficient evidence to validate clinical role.

    Covered Indications for corneal topography/pachymetry

    Covered when the test is performed for one of the following clinical indications

    Covered Indications: Anomalies of corneal size and shape; corneal ectasia; Fuchs corneal dystrophy; keratoconus; lamellar keratoplasty; marginal degeneration of the cornea; mechanical complications of corneal graft; Mooren's ulcer; nodular corneal degeneration; post-operative corneal transplant; post-operative high astigmatism after cataract or glaucoma surgery or lens implant surgery; pseudophakic bullous keratopathy; pterygium; secondary corneal edema.

    Coverage limited to these enumerated indications as listed in policy.

    LASIK coverage criteria

    Covered when ALL of the following are met:

    LASIK coverage: 1) Best-corrected visual acuity is 20/40 or worse; 2) Vision cannot be adequately corrected with corrective lens or contact lens, or patient is intolerant to contact lens; 3) Patient has a qualifying medical condition (e.g., keratoconus post-corneal transplant).20/40 or worse

    Prior authorization required to confirm criteria and member benefits.

    PRK coverage criteria

    Covered when ALL of the following are met:

    PRK coverage: 1) Best-corrected visual acuity is 20/40 or worse; 2) Vision cannot be adequately corrected with corrective lens or contact lens, or patient is intolerant to contact lens; 3) Patient has one of the listed corneal conditions (epithelial basement membrane dystrophy; keratoconus post-corneal transplant; Salzmann's degeneration; severe corneal epithelial erosions; superficial corneal dystrophies such as granular, lattice, and Reis-Buckler's).20/40 or worse

    Prior authorization required to confirm criteria and member benefits.

    PTK coverage criteria

    Covered when ALL of the following are met:

    PTK coverage: 1) Best-corrected visual acuity is 20/40 or worse; 2) Vision cannot be adequately corrected with corrective lens or contact lens, or patient is intolerant to contact lens; 3) Pathology or irregularity is located in the anterior 100 microns (one-third) of the cornea and the proposed total treatment area is at least 400 microns in thickness.20/40 or worse; anterior 100 microns; 400 microns treatment area

    Prior authorization required to confirm criteria and member benefits.

    LASIK — covered when ALL of the following are met

    SelectHealth covers LASIK when all criteria below are satisfied.

    LASIK criteria: 1) Best-corrected visual acuity is 20/40 or worse; 2) Vision cannot be adequately corrected with corrective lens or contact lens, or patient is intolerant to contact lens; 3) Patient has a qualifying medical condition (e.g., keratoconus post-corneal transplant).20/40 or worse

    From policy LASIK section; prior authorization required.

    PRK — covered when ALL of the following are met

    SelectHealth covers PRK when all criteria below are satisfied.

    PRK criteria: 1) Best-corrected visual acuity is 20/40 or worse; 2) Vision cannot be adequately corrected with corrective lens or contact lens or patient is intolerant to contact lens; 3) Patient has one of the listed corneal conditions (epithelial basement membrane dystrophy; keratoconus post-corneal transplant; Salzmann's degeneration; severe corneal epithelial erosions; superficial corneal dystrophies such as granular, lattice, and Reis-Buckler's).20/40 or worse

    From policy PRK section; prior authorization required.

    PTK — covered when ALL of the following are met

    SelectHealth covers PTK when all criteria below are satisfied.

    PTK criteria: 1) Best-corrected visual acuity is 20/40 or worse; 2) Vision cannot be adequately corrected with corrective lens or contact lens or patient is intolerant to contact lens; 3) Pathology or irregularity is located in the anterior 100 microns (one-third) of the cornea, and proposed total treatment area is at least 400 microns in thickness.20/40 or worse; anterior 100 microns; 400 microns treatment area

    From policy PTK section; prior authorization required.

    Aqueous shunt/stent devices — covered when ALL of the following are met

    SelectHealth covers specified glaucoma implants/stents when criteria below are met.

    EX-PRESS or Xen45 coverage: 1) Diagnosis of open-angle glaucoma or pseudoexfoliative glaucoma; 2) Failure of control of IOP with maximum tolerated medical therapy.

    Applies to EX-PRESS Mini Glaucoma Shunt and Xen45 Gel Stent.

    Ahmed or Baerveldt coverage: 1) Diagnosis of glaucoma (including primary open-angle, pseudoexfoliative, neovascular, uveitic, chronic angle-closure); 2) Failure of control of IOP with maximum tolerated medical therapy.

    Applies to Ahmed Valve and Baerveldt Implant.

    iStent/Hydrus coverage: 1) Procedure is combined with cataract surgery (not standalone except iStent infinite may be standalone); 2) Diagnosis of open-angle glaucoma or pseudoexfoliative glaucoma; 3) Patient is currently using at least one eyedrop for control.

    Covers iStent, iStent inject, iStent infinite, and Hydrus Microstent; document prior medical therapy.

    Covered Indications (Commercial)

    Select Health covers the following stents when ALL of the following are met:

    Coverage conditions: (1) Procedure is combined with cataract surgery (cannot be standalone), except iStent infinite which may be standalone; (2) Diagnosis of open-angle glaucoma or pseudoexfoliative glaucoma; (3) Patient is currently using at least one eyedrop for control.

    Exact device list includes iStent, iStent inject, iStent infinite, and Hydrus Microstent.

    INTACS (Intrastromal Corneal Ring Segments) Coverage Criteria

    Covered when ALL of the following are met:

    INTACS coverage criteria: 1) Patient is at least 21 years of age; 2) Progressive deterioration of vision; 3) Cannot achieve adequate functional vision on a daily basis with contact lenses or eyeglasses; 4) Clear central corneas; 5) Corneal thickness ≥ 450 microns at proposed incision site; 6) Corneal transplantation is the only alternative other than INTACS to improve vision.>= 450 microns

    These criteria reflect the FDA HDE approval conditions for INTACS; use outside HDE is excluded.

    Coverage Criteria for Ozurdex

    Covered when ALL of the following are met:

    Indication: Patient has one of: chronic non-infectious posterior uveitis; macular edema following BRVO; macular edema following CRVO; or diabetic macular edema.

    Applies to Ozurdex FDA-approved indications.

    Uveitis prerequisite: If indication is non-infectious posterior uveitis, there must be documented lack of response or intolerance to recently administered intraocular steroids.

    Document prior intraocular steroid therapy and response.

    Contraindications absent: Patient does not have ocular/periocular infections, advanced glaucoma, aphakia with rupture of posterior lens capsule, anterior chamber IOL with rupture of posterior lens capsule, or hypersensitivity to prednisone.

    All listed contraindications must be absent for coverage.

    Not Covered (Commercial and CHIP)

    Coverage stance and clinical consideration

    Commercial/CHIP policy: Select Health does not cover photobiomodulation therapy for dry age-related macular degeneration due to insufficient evidence of efficacy; it is considered experimental/investigational.

    Clinicians should counsel patients about out-of-pocket costs and uncertain risks/benefits if considering PBM.

    Medicare/Medicaid (coverage depends on external determinations)

    Medicare and Medicaid applicability

    Medicare: Coverage is determined by CMS; if CMS has not adopted a determination and InterQual criteria are not available, the Select Health Commercial policy applies.

    Providers should consult CMS NCD/LCD for Medicare coverage decisions.

    Medicaid (Select Health Community Care): Select Health Community Care policies typically align with State of Utah Medicaid policy and may use InterQual; state Medicaid rules may supersede commercial policy.

    Refer to Utah Medicaid resources for current state policies.

    Commercial Coverage Exclusion

    Select Health Commercial and CHIP stance

    Commercial exclusion: Telescopic lens implants are not covered for treatment of visual impairment associated with macular degeneration or any other condition because coverage of visual aids is specifically excluded in the Select Health Certificate of Coverage.

    Applies to Select Health Commercial and CHIP plans.

    CMS and Medicaid Determination

    Medicare and Medicaid policy alignment

    Medicare determination: Coverage is determined by CMS; if CMS has not adopted a determination and InterQual criteria are not available, the Select Health Commercial policy applies.

    For Select Health Community Care (Medicaid), policies typically align with Utah Medicaid and may use InterQual or NCD/LCD criteria.

    COVERAGE CRITERIA — Autologous serum eye drops excluded (experimental/investigational)

    Autologous serum eye drops exclusion: Select Health does NOT cover autologous serum eye drops for Select Health Commercial and CHIP plans because the service is considered experimental/investigational.

    This is the policy's stated coverage stance for autologous serum eye drops.

    Select Health considers procedures intended solely to improve appearance of functionally and histologically normal eyelid tissues (i.e., cosmetic blepharoplasty) to be non-reconstructive and not medically necessary. Preoperative evaluation should document any active ocular disease or contraindications (e.g., dry eye, thyroid eye disease) because these conditions may obviate or delay surgery. When functional impairment is not documented with objective testing or clinical findings, requests for blepharoplasty for cosmetic reasons will be denied.

    Surgical interventions for the anophthalmic socket (e.g., eyelid procedures to facilitate prosthesis wear) are considered reconstructive only when the member has an anophthalmic condition and documented difficulty fitting or wearing an ocular prosthesis. The policy notes that the published literature does not provide strong evidence supporting routine reconstructive benefit for socket-related dermatitis or temporal field limitations; coverage is therefore limited to cases where both the anophthalmic diagnosis and functional prosthesis-fit problems are documented and the member’s benefits allow the service.

    Select Health covers epithelium-off corneal crosslinking (CXL) when criteria are met and limits coverage to one lifetime treatment per eye using the FDA‑cleared KXL system with Photrexa/Photrexa. Corneal crosslinking performed concurrently with intrastromal corneal ring segment (ICRS/INTACS) placement is explicitly not covered and is considered experimental/investigational because current evidence is insufficient to establish safety and effectiveness of the combined procedure.

    In the available policy excerpt, Select Health identifies CPT code 0402T for corneal crosslinking but does not list any HCPCS codes. The document states no specific HCPCS codes were identified for corneal crosslinking in this excerpt.

    Select Health considers corneal hysteresis (CH) testing experimental/investigational for Commercial plan members and does not cover the test. Although devices such as the Reichert ORA have 510(k) clearance for biomechanical assessment and IOP measurement, the policy concludes CH testing lacks demonstrated clinical utility to guide management.

    The policy summarizes the evidence base and concludes there is insufficient evidence to validate the clinical role of corneal hysteresis measurement. Observational studies show associations between CH and glaucoma-related parameters, but the literature does not establish that CH measurement improves patient management or outcomes, and questions remain about measurement reliability and clinical application.

    Select Health does not cover corneal topography or pachymetry when these tests are performed solely as pre-service evaluations or post‑surgical assessments for patients undergoing vision-correction procedures that are themselves not covered. When submitted to support a covered corneal or optic indication, topography/pachymetry should be ordered and documented consistent with the listed covered indications (e.g., keratoconus, lamellar keratoplasty).

    Excimer laser procedures (LASIK, PRK, PTK) are covered only when all policy criteria are met, including best-corrected visual acuity and qualifying corneal pathology/depth. Procedures that do not meet the listed criteria (visual acuity threshold, inability to be corrected with lenses/contact lens intolerance, and specified corneal condition or depth requirements) are not covered.

    Select Health considers insertion of intraocular or lacrimal drug‑eluting implants (including placement into the lacrimal canaliculus, anterior chamber, or trabecular meshwork) to be experimental/investigational for glaucoma or ocular hypertension because long‑term safety and effectiveness data are lacking.

    The policy explicitly states that insertion of a drug‑eluting implant into the lacrimal canaliculus, anterior chamber, or trabecular meshwork (including punctal dilation with implant placement and implant removal) is considered experimental/investigational and is not covered due to insufficient evidence of long‑term safety and effectiveness.

    Select Health limits coverage of INTACS (intrastromal corneal ring segments/ICRS) to the FDA HDE indication for keratoconus. Use of INTACS for myopia or other non‑HDE indications is explicitly not covered and is considered experimental/investigational.

    For Ozurdex (0.7 mg dexamethasone implant) the policy lists specific contraindications. Patients with ocular or periocular infections (including herpes simplex keratitis, vaccinia, varicella, mycobacterial or fungal infections), advanced glaucoma, aphakia with rupture of the posterior lens capsule, anterior chamber intraocular lens with rupture of the posterior lens capsule, or hypersensitivity to prednisone are contraindicated for Ozurdex per the policy.

    Photobiomodulation (PBM) therapy for dry age‑related macular degeneration is considered investigational and not covered by Select Health Commercial and CHIP plans because evidence is insufficient to demonstrate efficacy. The policy notes an FDA marketing authorization for a PBM device but maintains that PBM remains experimental for the listed indications and lists CPT code 0936T as not covered.

    Select Health Commercial plans do not cover telescopic lens implants (implantable miniature telescope devices) as visual aids are specifically excluded under the Select Health Certificate of Coverage. Although the IMT may improve visual acuity in some studies, the policy frames it as an excluded visual aid and directs providers to member benefit language for applicability.

    The policy notes that mild to moderate visual field impairment is generally not clinically significant and does not by itself justify surgical intervention. Surgery is considered when visual field obstruction becomes severe enough to interfere with activities of daily living and is documented by objective testing.

    Procedures performed solely for cosmetic reasons — where no quantitative or qualitative functional impairment is documented — will be denied. The policy requires objective documentation (e.g., photographic views, taped/untaped visual field testing, MRD1 measurements) or clear functional impact on activities of daily living to support reconstructive indications; absent such documentation, cosmetic‑only requests are not covered.

    Coding and Billing

    CPT CodesCPT
    68899Unlisted procedure, lacrimal system
    HCPCS CodesHCPCS
    No codes listed
    Covered CPT Codes (Upper lid and brow ptosis)CPTCovered
    15822Blepharoplasty, upper eyelid
    15823Blepharoplasty, upper eyelid; with excessive skin weighting down lid
    67900Repair of brow ptosis (supraciliary, mid-forehead or coronal approach)
    67901Repair of blepharoptosis, frontalis muscle technique with suture or other material (e.g. banked fascial)
    67902Repair of blepharoptosis, frontalis muscle technique with autologous fascial sling (includes obtaining fascia)
    67903Repair of blepharoptosis, (tarso) levator resection or advancement, internal approach
    67904Repair of blepharoptosis, (tarso) levator resection or advancement, external approach
    67906Repair of blepharoptosis, superior rectus technique with fascial sling (includes obtaining fascia)
    67908Repair of blepharoptosis, conjunctivo-tarso-Muller's muscle-levator resection (e.g., Fasanella-Servat type)
    67909Reduction of overcorrection of ptosis
    1–10 of 12
    1/2
    Lower Lid BlepharoplastyCPTCovered
    15820Blepharoplasty, lower eyelid
    15821Blepharoplasty, lower eyelid; with extensive herniated fat pad
    Canthoplasty/CanthopexyCPTCovered
    21280Medical canthopexy (separate procedure)
    21282Lateral canthopexy
    67950Canthoplasty (reconstruction of canthus)
    Lid Retraction SurgeryCPTCovered
    67911Correction of lid retraction
    Blepharoplasty (Lower Eyelid)CPTCovered
    15820Blepharoplasty, lower eyelid
    15821Blepharoplasty, lower eyelid; with extensive herniated fat pad
    Blepharoplasty (Upper Eyelid)CPTCovered
    15822Blepharoplasty, upper eyelid
    15823Blepharoplasty, upper eyelid; with excessive skin weighting down lid
    Brow Ptosis RepairCPTCovered
    67900Repair of brow ptosis (supraciliary, mid-forehead or coronal approach)
    Upper Eyelid Blepharoptosis RepairCPTCovered
    67901Repair of blepharoptosis, frontalis muscle technique with suture or other material (e.g. banked fascial)
    67902Repair of blepharoptosis, frontalis muscle technique with autologous fascial sling (includes obtaining fascia)
    67903Repair of blepharoptosis, (tarso) levator resection or advancement, internal approach
    67904Repair of blepharoptosis, (tarso) levator resection or advancement, external approach
    67905Repair of blepharoptosis; frontalis sling with synthetic material
    67906Repair of blepharoptosis, superior rectus technique with fascial sling (includes obtaining fascia)
    67907Repair of blepharoptosis, frontalis suspension (includes fascial sling)
    67908Repair of blepharoptosis, conjunctivo-tarso-Muller's muscle-levator resection (e.g., Fasanella-Servat type)
    67909Reduction of overcorrection of ptosis
    Lid RetractionCPTCovered
    67911Correction of lid retraction
    Canthus Repair and Lid RepairCPTCovered
    21280Medical canthopexy (separate procedure)
    21282Lateral canthopexy
    67950Canthoplasty (reconstruction of canthus)
    67961Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness; up to one-fourth of lid margin
    67966Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness; over one-fourth of lid margin
    CPT Codes (corneal crosslinking)CPT
    0402TCollagen cross-linking of cornea (including removal of the corneal epithelium and intraoperative pachymetry when performed)
    CPT Codes (Corneal Crosslinking)CPTCovered
    0402TCollagen cross-linking of cornea (including removal of the corneal epithelium and intraoperative pachymetry when performed)
    CPT Codes (transplant/membrane procedures)CPT
    65778Placement of amniotic membrane on the ocular surface; without sutures
    65779Placement of amniotic membrane on the ocular surface; single layer, sutured
    65780Ocular surface reconstruction; amniotic membrane transplantation
    65781; limbal conjunctival autograft (e.g., cadaveric or living donor)
    65782; limbal conjunctival autograft (includes obtaining graft)
    HCPCS Codes (transplant/membrane)HCPCS
    V2790Amniotic membrane for surgical reconstruction, per procedure
    CPT Codes (corneal hysteresis)CPT
    92145Corneal hysteresis determination, by air impulse stimulation, unilateral or bilateral, with interpretation and report
    Covered CPT Codes (group)CPTCovered
    65400Excision of lesion, cornea (keratectomy, lamellar, partial, except pterygium)
    65785Implantation of intrastromal corneal ring segments
    Relevant ICD-10 Codes (selected groups)ICD-10
    Q11.2Microphthalmos
    Q13.4Other congenital corneal malformations
    H18.70Unspecified corneal deformity
    H18.711Corneal ectasia, right eye
    H18.712Corneal ectasia, left eye
    H18.713Corneal ectasia, bilateral
    H18.719Corneal ectasia, unspecified eye
    H18.601Keratoconus, unspecified, right eye
    H18.602Keratoconus, unspecified, left eye
    H18.603Keratoconus, unspecified, bilateral
    1–10 of 18
    1/2
    Corneal degeneration ICD-10 codesICD-10
    H18.461Peripheral corneal degeneration, right eye
    H18.462Peripheral corneal degeneration, left eye
    H18.463Peripheral corneal degeneration, bilateral
    H18.469Peripheral corneal degeneration, unspecified eye
    H18.49Other corneal degeneration
    Mechanical complications of corneal graftICD-10
    T85.318ABreakdown (mechanical) of other ocular prosthetic devices, implants and grafts, initial encounter
    T85.318DBreakdown (mechanical) of other ocular prosthetic devices, implants and grafts, subsequent encounter
    T85.318SBreakdown (mechanical) of other ocular prosthetic devices, implants and grafts, sequela
    T85.328ADisplacement of other ocular prosthetic devices, implants and grafts, initial encounter
    T85.328DDisplacement of other ocular prosthetic devices, implants and grafts, subsequent encounter
    T85.328SDisplacement of other ocular prosthetic devices, implants and grafts, sequela
    T85.398AOther mechanical complication of other ocular prosthetic devices, implants and grafts, initial encounter
    T85.398DOther mechanical complication of other ocular prosthetic devices, implants and grafts, subsequent encounter
    T85.398SOther mechanical complication of other ocular prosthetic devices, implants and grafts, sequela
    Additional corneal and transplant-related ICD-10 codesICD-10
    H16.071Perforated corneal ulcer, right eye
    H16.072Perforated corneal ulcer, left eye
    H16.073Perforated corneal ulcer, bilateral
    H16.079Perforated corneal ulcer, unspecified eye
    H16.301Unspecified interstitial keratitis, right eye
    H16.302Unspecified interstitial keratitis, left eye
    H16.303Unspecified interstitial keratitis, bilateral
    H16.309Unspecified interstitial keratitis, unspecified eye
    H17.10Central corneal opacity, unspecified eye
    H17.11Central corneal opacity, right eye
    1–10 of 12
    1/2
    Covered CPT CodesCPTCovered
    65400Excision of lesion, cornea (keratectomy, lamellar, partial, except pterygium)
    65760Keratomileusis
    65765Keratophakia
    65767Epikeratoplasty
    65771Radial keratotomy
    66999Unlisted procedure, anterior segment of eye
    Covered HCPCS CodesHCPCSCovered
    S0800Laser in-situ keratomileusis (LASIK)
    S0810Photorefractive keratectomy (PRK)
    S0812Phototherapeutic keratectomy (PTK)
    Covered CPT Codes (glaucoma devices)CPTCovered
    0253TInsertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the suprachoroidal space
    0449TInsertion of aqueous drainage device, without extraocular reservoir, internal approach, into the subconjunctival space; initial device
    0450Teach additional device (List separately in addition to code for primary procedure)
    0671TInsertion of anterior segment aqueous drainage device into the trabecular meshwork, without external reservoir, and without concomitant cataract removal, one or more
    66179Aqueous shunt to extraocular equatorial plate reservoir, external approach; without graft
    66180with graft (revised)
    66183Insertion of anterior segment aqueous drainage device, without extraocular reservoir; external approach
    66185Revision of aqueous shunt to extraocular equatorial plate reservoir; with graft
    66989Extracapsular cataract removal with insertion of intraocular lens prosthesis; complex; with insertion of anterior segment aqueous drainage device
    66991Extracapsular cataract removal with insertion of intraocular lens prosthesis; with insertion of anterior segment aqueous drainage device
    1–10 of 11
    1/2
    HCPCS Codes (glaucoma devices)HCPCSCovered
    C1783Ocular implant, aqueous drainage assist device
    L8612Aqueous shunt
    Covered CPT Codes (INTACS)CPTCovered
    65785Implantation of intrastromal corneal ring segments
    CPT Codes (Ozurdex segment)CPT
    67027Implantation of intravitreal drug delivery system (eg, ganciclovir implant), includes concomitant removal of vitreous
    67028Intravitreal injection of a pharmacologic agent (separate procedure)
    HCPCS Codes (Ozurdex)HCPCS
    J7312Injection, dexamethasone (Ozurdex), intravitreal implant, 0.1mg
    Not covered CPT Codes (investigational)CPTNot Covered
    0936TPhotobiomodulation therapy of retina, single session
    CPT Codes (ocular telescope prosthesis)CPT
    0308TInsertion of ocular telescope prosthesis including removal of crystalline lens or intraocular lens prosthesis
    HCPCS Codes (telescopic IOL)HCPCS
    C1840Lens, intraocular (telescopic)

    Provider Actions, Authorization & Documentation

    Prior Authorization

    Prior authorization and benefit verification required

    Select Health requires prior authorization for many specialty ophthalmic treatments and devices. Prior authorization is required to confirm that the member meets the policy-specific coverage criteria and that the member’s benefit plan covers the requested service. Failure to obtain prior authorization or to verify benefits may result in claim denial or lack of coverage.

    • Prior authorization required for services described in policy sections unless otherwise noted by Medicare/Medicaid program rules.
    • Verify member benefits at time of request; benefit eligibility determines final coverage.
    Documentation Required

    Prior authorization — required documentation and submission materials

    Prior authorization reviews require specific clinical documentation to support medical necessity. Submit complete documentation with the request; missing materials may lead to denial.

    Background and Evidence Summary

    Dry eye is a common tear‑film disorder, especially in adults over age 40. First‑line therapies include lubricating artificial tears and topical anti‑inflammatory agents (for example, cyclosporine or lifitegrast). Autologous serum eye drops are prepared from the patient's blood and contain biologically active components and growth factors similar to natural tears; preparations reported in the literature vary in concentration from 20% to 100% and are not standardized.

    Autologous serum eye drops are topical preparations made from a patient’s own blood after separation of cellular and liquid components. They contain nutrients and growth factors found in natural tears and have been used as an alternative tear substitute for refractory dry eye and ocular surface disease; preparation methods and concentrations in the literature vary widely.

    Dermatochalasis refers to excess eyelid skin (often age‑related) that can protrude over the lid margin and impair vision. Blepharoplasty is commonly performed to correct dermatochalasis when it produces functional visual impairment; preoperative evaluation should rule out active eye disease and contraindications to surgery.

    Blepharoptosis (ptosis) is drooping of the upper eyelid that can obstruct the visual axis and often requires ptosis repair rather than a cosmetic blepharoplasty. Functional thresholds used in this policy include an upper eyelid MRD1 ≤ 2 mm and superior visual field loss thresholds consistent with the AAO OTA literature to support surgical benefit.

    Blepharospasm is involuntary, often debilitating, eyelid muscle twitching. First‑line therapy is botulinum toxin injections; if injections fail or are not effective, surgical myectomy may be considered as a subsequent option.

    Blepharochalasis is a rare condition in younger patients causing redundant upper eyelid skin that can conceal the tarsal margin and impair the visual field. When conservative management is ineffective and functional impairment is documented, surgical correction may be indicated.

    Policy Revision History

    2023-07-11addition

    Commercial Plan Policy: added coverage criteria for the iStent infinite device.

    2023-08-08modification

    Commercial Plan Policy: modified criteria in sections I and II to require automated peripheral or superior visual field testing (eyelids taped and untaped) showing improvement of 30% or 12 degrees in number of points seen on taped testing.

    2024-09-19clarificationLatest
    Policy Summary
    PayerSelectHealth
    PolicyAutologous Serum Eye Drops (coverage criteria)
    Policy CodePolicy N/A
    Change TypeMaterial criteria modifications and device additions
    Effective DateNov 14, 2023
    Last ReviewDec 1, 2024
    Next Review DateDec 1, 2024
    Key ActionObtain prior authorization with taped and untaped automated visual field testing and required photos/documentation to demonstrate functional impairment when seeking coverage.
    SourceLink
    On This Page
    Coverage Criteria and Medical NecessityCoding and BillingProvider Actions, Authorization & DocumentationBackground and Evidence SummaryPolicy Revision History
  1. Required submission materials commonly requested: taped and untaped bilateral automated visual field test results (include points seen/not seen), lateral and full-face photographs with corneal light reflex (primary gaze, down-gaze, side and oblique views), and documentation of impact on activities of daily living (ADL).
  2. For procedures such as excimer laser surgery and blepharoplasty, include best-corrected visual acuity, inability to correct with lenses or documented contact lens intolerance, and photographic evidence correlating with visual field findings.
  3. Failure to provide taped/untaped visual field results, ADL impact documentation, and required photos may result in denial.
    4. Prior Authorization

    Medical indication and program-specific authorization

    Medical indication and documentation of the specific covered diagnosis are required for coverage decisions. Coverage is applied only when the member’s clinical presentation meets the listed indications and benefit coverage at the time of service.

    • Document the medical indication from the policy's listed covered conditions when ordering tests (e.g., corneal topography/pachymetry) or requesting procedures.
    • For corneal epithelial/limbal stem cell transplants, document graft source and indication.
    • When criteria depend on program rules (Medicare/Medicaid), follow applicable CMS/state criteria.
    Denial Risk

    Not covered / investigational services

    Certain services are explicitly not covered as experimental/investigational. Do not submit prior authorization requests for these services expecting coverage.

    • Autologous serum eye drops — not covered (experimental/investigational).
    • Photobiomodulation therapy for dry AMD — not covered (investigational).
    • Corneal hysteresis testing — not covered for commercial members (investigational).
    • Telescopic lens implants — not covered per Certificate of Coverage.
    Billing Rule

    Coverage determination and billing/coding guidance

    Coverage determinations depend on the member’s benefit plan and on applicable billing codes. Include applicable CPT/HCPCS codes on prior authorization submissions; omission may delay processing.

    • Billing code note: CPT 68899 (Unlisted procedure, lacrimal system) is listed for certain tear/ocular surface treatments.
    • Include the CPT and HCPCS codes relevant to the device or procedure performed (see policy code lists).
    • Codes in the policy are informational; inclusion does not guarantee coverage — confirm member benefit plan.
    Documentation Required

    Visual field documentation requirement

    Visual field testing documentation is a common and critical requirement for eyelid and visual-field–related procedures. Provide both taped and untaped automated or manual visual field testing showing required improvement when applicable.

    • For blepharoplasty and ptosis repair, provide complete taped and untaped bilateral visual field exams, including numeric points seen/not seen.
    • Policy criteria may require a demonstrated improvement (e.g., 30% or 12 degrees) on taped testing versus untaped.
    • When computerized testing is unavailable, manual visual field testing may be accepted; document reasons if testing is not possible.
    Denial Risk

    Denial triggers — documentation and criteria failures

    Some procedures have specific denial triggers when policy clinical thresholds are not met. Confirm all listed clinical criteria before submitting a prior authorization request to reduce the risk of denial.

    • Excimer laser procedures (LASIK/PRK/PTK) — requests may be denied if documentation does not show best-corrected visual acuity of 20/40 or worse, inability to correct vision with lenses, or the specific qualifying corneal pathology.
    • Glaucoma device implants may be denied if diagnosis or failure of maximum tolerated medical therapy is not documented.
    • Standalone implantation of certain stents (except iStent infinite) will be denied if not performed with cataract surgery.
    Prior Authorization

    Coverage requirement — INTACS (HDE)

    INTACS coverage follows the FDA HDE conditions — all listed criteria must be met. Failure to meet any HDE criteria will result in denial.

    • All INTACS criteria must be documented: age ≥ 21, progressive deterioration of vision, inability to achieve adequate daily functional vision with glasses or contacts, clear central cornea, corneal thickness ≥ 450 microns at proposed incision site, and corneal transplantation is the only other option.
    • INTACS for myopia or other non‑keratoconus indications is excluded and considered experimental/investigational.
    Step Therapy

    Therapy prior requirement and step therapy context

    Some policies require prior failure of specific therapies before device implantation or coverage of certain treatments. Document prior therapies and reasons for failure or intolerance when required.

    • For certain glaucoma implants, document failure of maximum tolerated medical therapy prior to implantation.
    • For Ozurdex in non-infectious posterior uveitis, document lack of response or intolerance to recent intraocular steroids.
    • Conservative therapies (e.g., artificial tears, topical anti-inflammatories, contact lenses) should be tried and documented when the policy lists conservative management as a prerequisite.
    Note

    Verify benefits, contacts, and patient counseling

    Providers should verify benefits and contact plan resources for prior authorization questions or member-specific coverage determinations. Discuss potential out-of-pocket costs and risks with patients before proceeding.

    • Verify member benefits at the time of request; benefits determine coverage applicability.
    • Members may contact Customer Service at the number on their ID card for benefit questions; providers may call Select Health Provider Relations at (801) 442-3692.
    • Counsel patients on out-of-pocket costs and procedural risks; refer to the member's contract benefits for coverage details.

    Blepharospasm is involuntary eyelid muscle contraction; botulinum toxin injections are the standard initial therapy and myectomy is a surgical option for refractory cases.

    Margin Reflex Distance 1 (MRD1) is the distance from the upper eyelid margin to the corneal light reflex; a normal MRD1 is approximately 4–5 mm. An MRD1 of ≤ 2 mm is generally associated with significant superior visual field impairment and is accepted as a functional indication for surgery.

    Ectropion is outward turning or sagging of the eyelid (usually the lower lid) that can cause exposure, dryness, tearing, and corneal risk; surgical repair is indicated when medical management is inadequate or when corneal complications occur.

    Entropion is an inward rotation of the eyelid causing lashes to rub the ocular surface, leading to irritation and possible corneal damage. Conservative measures are often tried first, with surgery performed when symptoms or corneal findings warrant correction.

    The term epithelium‑off CXL (epi‑off) describes corneal crosslinking in which the corneal epithelium is removed to allow riboflavin penetration prior to ultraviolet light activation; Select Health limits coverage to the epithelium‑off technique using Photrexa/KXL when criteria are met.

    Epithelium‑on (transepithelial) CXL refers to crosslinking techniques in which the corneal epithelium is left intact and riboflavin loading is prolonged. The evidence for epi‑on and accelerated protocols is less robust, and these approaches are not considered equivalent to the FDA‑cleared epi‑off Photrexa/KXL approach for coverage purposes.

    An autograft is limbal epithelial tissue harvested from the patient’s contralateral healthy eye and transplanted to the damaged eye. Autografts may avoid immunosuppression and are an established method for limbal stem cell transplantation when appropriate donor tissue is available.

    An allograft for limbal stem cell transplantation uses donor tissue from cadaveric sources or living relatives (eye bank) and may require consideration of immunologic risk and potential immunosuppression depending on the graft source and technique.

    Tissue‑cultured limbal stem cell techniques expand limbal or prelimbal stem cells in culture from sources such as cadaveric tissue or amniotic epithelial cells; these methods are promising but heterogeneous and currently characterized as emerging rather than standard of care.

    Amniotic membrane transplantation can serve as a carrier for cultured epithelial or limbal stem cells and may provide anti‑inflammatory properties; CPT codes for amniotic membrane procedures (65778–65780) are listed in the policy for these techniques.

    Corneal hysteresis (CH) is a biomechanical measurement of the cornea’s viscoelastic damping obtained by inducing corneal movement with an air pulse (devices such as the Reichert ORA). While CH may correlate with glaucoma risk factors and RNFL decline in some studies, the policy states that CH measurement has not been shown to improve patient management or outcomes and remains investigational for coverage.

    The literature summarizes CH as a biomechanical metric reflecting corneal response to deformation and notes associations with progressive optic nerve or RNFL changes; however, the evidence does not yet support routine clinical implementation for prognosis or management decisions.

    Keratoconus is a noninflammatory progressive thinning and bulging of the central cornea that causes irregular astigmatism and can impair vision. Corneal mapping (topography) and pachymetry are key diagnostic tools used to assess and monitor keratoconus.

    Corneal topography is computerized mapping of corneal curvature producing a color '3‑D' map that helps evaluate astigmatism, irregularities, and plan surgical or contact lens management.

    Corneal pachymetry is a noninvasive ultrasonic measurement of central corneal thickness used in corneal disease assessment and glaucoma risk evaluation; CPT code 76514 is listed for pachymetry in the policy.

    LASIK combines automated lamellar keratoplasty to create a corneal flap with excimer laser ablation (PRK) to reshape the stromal bed. PRK removes the surface epithelium and ablates tissue; PTK treats anterior stromal pathology. Coverage of these excimer procedures is contingent on meeting the policy’s visual acuity, corrective‑lens failure/intolerance, and corneal pathology criteria.

    PTK (phototherapeutic keratectomy) is an excimer laser procedure to remove anterior stromal opacities or lesions while preserving a smooth corneal surface; policy coverage requires pathology limited to the anterior corneal layers (anterior 100 microns) and minimum treatment thickness thresholds when applicable.

    PRK is a surface ablation excimer laser procedure in which the epithelium is removed and stromal ablation performed to reshape the cornea for refractive correction; coverage requires specified diagnostic and visual acuity criteria to be met.

    LASIK involves creating an epithelial flap, reshaping the underlying stromal bed with an excimer laser, and repositioning the flap without sutures; it generally has fewer healing complications and less postoperative pain than PRK.

    PTK is an excimer procedure that removes anterior stromal opacities or elevated corneal lesions and may induce refractive changes such as hyperopia or glare; selection for coverage depends on depth and extent of pathology.

    The iStent infinite system consists of three iStent inject W stents placed into the trabecular meshwork over at least four clock hours; the device received FDA 510(k) clearance for standalone use and Select Health lists criteria for coverage (including stent placement combined with cataract surgery except for iStent infinite which may be standalone).

    The XEN45 Gel Stent is an ab interno gelatin microstent approved in 2016 with evidence showing intraocular pressure lowering and medication reduction; Select Health includes it among covered devices when policy criteria are met.

    The EX‑PRESS shunt is an internal aqueous shunt with published evidence of IOP reduction; complication rates vary by placement technique (under conjunctiva versus under a scleral flap).

    INTACS/ICRS are semicircular PMMA segments implanted in the corneal stroma to flatten the central cornea; Select Health covers INTACS only under the FDA HDE for keratoconus and requires meeting HDE‑specified clinical criteria (e.g., age ≥ 21 years, progressive deterioration, corneal thickness ≥ 450 microns at incision site).

    An HDE (Humanitarian Device Exemption) is the FDA regulatory pathway under which some devices (e.g., INTACS for keratoconus) are approved for limited indications; Select Health aligns coverage of INTACS with the HDE criteria.

    Ozurdex is a 0.7 mg dexamethasone intravitreal implant delivered via a single‑use applicator and FDA‑approved for indications including BRVO/CRVO macular edema, non‑infectious posterior uveitis, and diabetic macular edema in specified patients; Select Health lists the approved indications and contraindications in policy criteria.

    Photobiomodulation (PBM) therapy delivers specific wavelengths of light to retinal tissue to stimulate mitochondrial enzymes and modulate metabolic function; despite an FDA marketing authorization for a device, Select Health considers PBM investigational for dry AMD and does not cover it under Commercial/CHIP plans.

    The Implantable Miniature Telescope (IMT) is an intraocular telescopic prosthesis that magnifies central images to project onto healthier perimacular retina and may improve central visual acuity. Although studies show vision improvement in some patients, Select Health notes limited long‑term evidence for safety and outcomes and excludes telescopic lens implants under Commercial plans because visual aids are excluded under the Certificate of Coverage; low‑vision therapy and external visual aids are alternatives.

    Low‑vision therapy aims to maximize use of residual vision through adaptations and training to improve functional ability, safety, and independence for people whose vision cannot be corrected to near‑normal by standard restorative interventions; it is presented as a non‑implant alternative to devices such as IMT.

    Commercial Plan Policy: simplified criterion C-3 to state 'Patient is currently using at least one eyedrop for control.'

    Policy-level status: This document reflects a modified policy with effective date and review information recorded in the policy history; providers should verify the member’s benefit coverage and prior authorization requirements at the time of service.