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Active Policy; No Longer Scheduled For Routine Literature Review
Medical Policy: 09.03.05
Original Effective Date: January 2002
Reviewed: October 2008
Revised: October 2008
This policy applies to all products unless specific contract
limitations, exclusions or exceptions apply. Please refer to the member's coverage
manual for benefit availability. Managed care guidelines related to referral authorization,
and precertification of inpatient hospitalization, home health, home infusion and
hospice services apply.
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.
Policy:
PTK may be considered medically necessary for treatment of the following conditions:
- Corneal scar and opacities
- Anterior corneal dystrophy
- RCE when refractory to mechanical surgical treatment such as, corneal micropuncture a or epithelial curettage
PTK is considered not medically necessary when used as an alternative to a superficial mechanical keratectomy in treating patients with superficial corneal dystrophy, epithelial membrane dystrophy, and irregular corneal surfaces due to Salzmann's nodular degeneration or keratoconus nodules.
PTK is considered investigational for any condition not listed above, including but not limited to recurrent corneal erosions, and infectious keratitis.
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Procedure Codes and Billing
Guidelines:
- To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- HCPCS 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.
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New information or technology that would be relevant for Wellmark to consider when this policy is next reviewed may be submitted to:
Wellmark Blue Cross and Blue Shield
Medical Policy Analyst
Station 304
636 Grand Ave
Des Moines, Iowa 50309
*Current Procedural Terminology © 2009 American Medical Association. All Rights Reserved.
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.
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