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Medical Policy: 09.03.05
Original Effective Date: January 2002
Reviewed: December 2011
Revised: December 2010
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Phototherapeutic keratectomy (PTK) involves the use of the excimer laser to treat visual impairment or irritative symptoms relating to diseases of the anterior cornea by sequentially ablating uniformly thin layers of corneal tissue. Phototherapeutic keratectomy may be performed in the office setting using topical anesthesia. Phototherapeutic keratectomy must be distinguished from photorefractive keratectomy, which involves the use of the excimer laser to correct refractive errors of the eye. (i.e., myopia, astigmatism, hyperopia, and presbyopia).
PTK functions by removing anterior stromal opacities or eliminating elevated corneal lesions while maintaining a smooth corneal surface.
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Prior Approval:
Not applicable
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Policy:
PTK may be considered medically necessary for treatment of the following conditions:
- Corneal scar and opacities
- Anterior corneal dystrophy
- Recurrent corneal erosions (RCE) refractory to mechanical surgical treatment such as, corneal micropuncture a or epithelial curettage
- Salzmann’s corneal degeneration
PTK is considered investigational for any condition not listed above, including but not limited to infectious keratitis.
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- S0812 phototherapeutic keratectomy.
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Selected References:
- The Medical Policy Reference Manual (MPRM) developed by the Blue Cross Blue Shield Association Health Management Systems, based on the Technology Evaluation Center (TEC) criteria.
- Amano S, Oshika T, Tazawa Y, Tsure T. Long-term follow-up of excimer laser phototherapeutic keratectomy. Japanese Journal of Ophthalmology 1999 Nov-Dec; 43(6): 513-6.
- Morad Y, Haviv D, Zadok D, Krakowsky D, Hefetz L, Nemet P. Excimer laser phototherapeutic keratectomy for recurrent corneal erosion. Journal of Cataract and Refractory Surgery 1998 Nov; 24(11): 1418-9.
- Jain, S, Austin DJ. Phototherapeutic keratectomy for treatment of recurrent corneal erosion. Journal of Cataract and Refractive Surgery 1999 Dec; 25 (12): 1610-4.
- Ho CL, Tan DT, Chan WK. Excimer laser phototherapeutic keratectomy for recurrent corneal erosions. Annals of the Academy of Medicine, Singapore 1999 Nov; 28 (6): 787-90.
- Fagerholm P. Phototherapeutic keratectomy: 12 years of experience. ACTA Ophthalmologica Scandinavica 2003;81:19-32.
- Stewart GO, Pararajasemaram P, Cazabon J and Morrell AJ. Visual and symptomatic outcome of excimer phototherapeutic keratectomy (PTK) for corneal dystrophies. Eye 2002;16:126-131.
- Maini R, Loughnan MS. Phototherapeutic keratectomy re-treatment for recurrent corneal erosion syndrome. British Journal of Ophthalmology 2002;86:270-272.
- Stewart OG, Morrell AJ. Management of band keratopathy with excimer phototherapeutic keratectomy: visual, refractive, and symptomatic outcome. Eye 200317:233-237.
- Myron Yanoff and Jay S. Duker. Ophthalmology, 3rd ed. Mosby Elsevier, 2008.
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Policy History:
Date Reason Action
December 2010 Annual review Policy revised
December 2011 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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