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Medical Policy: 09.03.06
Original Effective Date: January 2002
Reviewed: April 2012
Revised: April 2012
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:
Refractive keratoplasty is a generic term that includes all surgical procedures on the cornea to improve vision by changing the refractive index of the corneal surface. Refractive keratoplasties include the following surgeries:
Radial Keratotomy (RK) is a surgical correction for myopia (nearsightedness). Using a high-powered microscope, the physician places microincisions (usually eight or fewer) on the surface of the cornea in a pattern much like the spokes of a wheel. The incisions are very precise in terms of depth, length, and arrangement. The microincisions allow the central cornea to flatten, thus reducing the convexity of the cornea, which produces an improvement in vision.
Photorefractive Keratectomy (PRK) uses a computerized laser to correct myopia (nearsightedness). The excimer laser is well-suited for cornea reshaping, because the removal of just tiny amounts of tissue can produce the results needed to correct nearsightedness. The excimer laser produces a beam of ultraviolet light in pulses that last only a few billionths of a second. Each pulse removes a microscopic amount of tissue by evaporating it, producing very little heat and usually leaving underlying tissue almost untouched. Overall, the surgery takes approximately 10–20 minutes; however, the use of the laser beam lasts only 15–40 seconds.
Automated Lamellar Keratoplasty (ALK) can correct hyperopia. For the treatment of moderate farsightedness, the cornea is opened across the top to form a type of “cap,” using an automated instrument. When the “cap” is positioned back into its original location on top of the eye, microscopic scar tissue is formed, causing the “cap” to bulge out, thus correcting the overly flattened cornea that is associated with hyperopia. Almost like Velcro, the cornea and “cap” adhere to each other, eliminating the need for sutures. Normally, one eye is treated at a time, with about 3 to 4 weeks allowed between each eye surgery. To ease any discomfort, the eye is anesthetized with special drops, and the patient is given a mild sedative to remain relaxed and aware throughout the procedure.
Astigmatic Keratotomy is a refractive surgical procedure similar to Radial Keratotomy (RK). Transverse or arcuate incisions are made to the paracentral cornea to alter its curvature in order to decrease or eliminate corneal astigmatism. Limbal relaxing incisions (LRIs) are a variation of the astigmatic keratotomy procedure. Incisions are placed on the peripheral aspect of the cornea, and may be used to treat low to moderate degrees of astigmatism.
Minimally Invasive Radial Keratotomy (mini-RK) is intended in cases of myopia, to alter the cornea’s shape and consequently the refraction by reducing the millimeters of cornea that are incised.
Hexagonal Keratotomy is a form of refractive corneal surgery used to treat naturally occurring hyperopia (far-sightedness) and presbyopia (loss of accommodation in the eyes in advancing age) following radial keratotomy. A hexagonal pattern of intersecting incisions in the cornea is used in performing this procedure.
All of the above procedures can be used alone or in combination to produce the optimal result for a given patient.
Keratomileusis involves removing, freezing, and lathing the patient’s cornea, followed by its replacement onto the corneal bed. This surgery has been proposed for myopia and aphakic hyperopia (aphakia is the absence of the lens of the eye).
Keratophakia involves removing the patient’s cornea followed by placement of a lathed donor cornea beneath the recipient’s cornea, which is then reattached. This surgery has been proposed for aphakic hyperopia.
Epikeratophakia (lamellar keratoplasty) involves suturing a prelathed donor cornea onto the surface of the recipient’s cornea. This surgery has been proposed as a means of correcting adult and pediatric aphakia, keratoconus (a conical protrusion of the cornea, caused by thinning of the stroma, and resulting in major changes in the refractive power of the eye), and myopia.
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Prior Approval:
Not applicable
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Policy:
Epikeratophakia (epikeratoplasty) is considered medically necessary in the treatment of aphakia.
Radial keratotomy is considered medically necessary in the treatment of myopia that cannot be corrected with lenses (eyeglasses, contacts).
Corneal relaxing incisions or corneal wedge resections to correct a high degree of astigmatism (>3 diopters) resulting from a medically necessary surgery (e.g. post-cataract, post-corneal transplant) is considered medically necessary for patients who are intolerant of or cannot obtain adequate functional vision with lenses (eyeglasses, contacts).
Astigmatic keratotomy is considered not medically necessary for correction of refractive errors other than surgically induced astigmatism as indicated above.
Photorefractive keratectomy (PRK) is considered not medically necessary for correction of refractive errors.
The other refractive keratoplasty procedures listed under the Description section of the policy, (keratophakia, standard keratomileusis (ALK), minimally invasive radial keratotomy, and hexagonal keratotomy), are considered investigational for correction of refractive errors.
Also see separate policies regarding Phototherapeutic Keratectomy, policy 09.03.05 and Implantation of Intrastromal Corneal Ring Segments, policy 09.03.09.
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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.
- 65767 Epikeratoplasty
- 65771 Radial Keratotomy
- 65772 Corneal relaxing incision for correction of surgically induced astigmatism
- 65775 Corneal wedge resection for correction of surgically induced astigmatism
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Selected References:
- Lee JB, Kim JS, Choe C, Seong GH, Kim EK. Comparison of two procedures; photorefractive keratectomy versus laser in situ keratomileusis for low to moderate myopia. Japanese Journal of Ophthalmology 2001 Set-Oct; 45(5):487-91.
- Bower K, Weichel E, Kim T. Overview of refractive surgery. American Family Physician 2001 Oct; 64 (7).
- American Academy of Ophthalmology Preferred Practice Patterns Committee. Preferred Practice Pattern® Guidelines. Comprehensive Adult Medical Eye Evaluation. San Francisco, CA: American Academy of Ophthalmology; 2005. Available at: http://www.aao.org/ppp.
- Murray A, Jones L, Milne A, et al. A Systemic Review of the Safety and Efficacy of Elective Photorefractive Surgery for the Correction of Refractive Error. Aberdeen, Scotland: Health Services Research Unit, University of Aberdeen; 2005. Available at: http://www.nice.org.uk/page.aspx?o=ip320review.
- National Institute for Health and Clinical Excellence (NICE). IPG 164 Photorefractive (laser) surgery for the correction of refractive errors: Guidance. March 2006. Accessed November 9, 2009. Available at: http://www.nice.org.uk/page.aspx?o=IPG164guidance
- AmericanAcademy of Ophthalmology Refractive Management/Intervention Panel. Preferred Practice Pattern®Guidelines. Refractive Errors & Refractive Surgery. San Francisco, CA: American Academy of Ophthalmology; 2007. Available at: http://www.aao.org/ppp.
- Yanoff & Duker: Ophthalmology, 3rd ed. Part 3- Refractive Surgery. Copyright © 2008 Mosby, An Imprint of Elsevier.
- Barsam A, Allan B. Excimer laser refractive surgery versus phakic intraocular lenses for the correction of moderate to high myopia. Cochrane Database Syst Rev. 2010;(5):CD007679
- ECRI. Conductive Keratoplasty for Refractive Errors. Plymouth Meeting (PA): 2011 June 15. ECRI Institute’s Health Technology Assessment Information Service; [Hotline Response]. Also available: http://www.ecri.org.
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Policy History:
Date Reason Action
April 2011 Annual review Policy renewed
April 2012 Annual review Policy revised
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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 © 2012 American Medical Association. All Rights Reserved.
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