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Medical Policy: 09.03.06
Original Effective Date: January 2002
Reviewed: April 2008
Revised: January 2006
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:
Corneal remodeling is a term that includes all surgical procedures on the cornea to improve vision by changing the refractive index of the corneal surface. Corneal remodeling procedures include the following surgeries:
Photorefractive Keratectomy (PRK) uses a computerized laser to correct myopia and hyperopia. The excimer laser is well-suited for corneal reshaping, because the removal of just tiny amounts of tissue can produce the results needed to correct nearsightedness, or farsightedness. 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.
LASIK (laser in situ keratomileusis) can correct myopia and hyperopia. The cornea is opened to form a type of “cap” using an automated instrument (automated keratome). The exposed corneal tissue (stroma) is exposed to the excimer laser altering the shape of the cornea and correcting the refractive error. When the cap is positioned back onto its original location on top of the eye, the cornea and cap adhere to each other, eliminating the need for sutures.
Intrastromal corneal ring segments are two curved clear plastic pieces that form a ring and are surgically implanted in the perimeter of the cornea to alter its shape and correct certain types of nearsightedness caused by keratoconus. One such device, marketed under the trade name Intacs®, has been approved under the Humanitarian Device Exemption program by the FDA for keratoconus patients who are no longer able to achieve adequate vision using contact lenses or glasses, and for whom corneal transplant is the only other option.
Policy:
PRK and LASIK may be considered medically necessary procedures to correct refractive errors which cannot be corrected with lenses (with eyeglasses or contacts).
Implantation of FDA approved intrastromal corneal rings may be considered medically necessary for keratoconus patients who meet all of the following criteria:
- 21 years of age or older
- No longer able to achieve adequate vision using contact lenses or glasses
- Corneal transplant is the only other option
Intrastromal corneal ring implants are considered investigational for all other conditions and applications.
Also see the separate policy regarding phototherapeutic keratectomy, policy 09.03.05.
Corneal remodeling procedures are considered not medically necessary when performed solely to eliminate the use of refractive lenses (eyeglasses or contacts) because it is considered cosmetic.
Prior approval is recommended. Submit a prior approval now.
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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 code S0800 for LASIK
- HCPCS code S0810 for photorefractive keratectomy
- CPT code 0099T for implantation of intrastromal corneal ring segments
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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).
- ECRI. Intrastromal Corneal Ring Segments (Intacs Prescription Inserts) for Keratoconus. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2008 March 21. (ECRI Hotline Response) Also available: http://www.ecri.org.
- ECRI. Intrastromal Corneal Ring Segments (Intacs Prescription Inserts) for Refractive Errors. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2008 March 21. (ECRI Hotline Response) Also available: http://www.ecri.org.
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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, IA 50309
*Prior Approval is recommended for this policy.
**Current Procedural Terminology © 2008 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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