Corneal surgery is performed to change the shape of the cornea which will correct vision problems such as myopia (nearsightedness), hyperopia (farsightedness), and astigmatism. Corneal surgeries performed for this purpose may include radial keratotomy, photorefractive keratectomy (PRK), laser-assisted in-situ keratomileusis (LASIK), keratomileusis, keratophakia, and epikeratoplasty.

Phototherapeutic keratectomy (PTK) involves the use of the excimer laser to treat visual impairment or irritative symptoms relating to diseases of the anterior cornea. PTK functions by removing anterior stromal opacities or eliminating elevated cornea lesions while maintaining a smooth corneal surface.

Intrastromal corneal ring segments (i.e., INTACS) when provided in accordance with the Humanitarian Device Exemption (HDE) specifications of the United States Food and Drug Administration (U.S. FDA), consist of micro-thin methylmethacrylate inserts of variable thickness that are implanted on the perimeter of the cornea.  They are used in refractive surgery to correct mild myopia (see above), and as a treatment of keratoconus.  The inserts help restore vision in keratoconus patients by flattening and repositioning the cornea.

Corneal collagen cross-linking (CXL) is a photochemical procedure for the treatment of progressive keratoconus and corneal ectasia. Keratoconus is a dystrophy of the cornea characterized by progressive deformation (steepening) of the cornea while corneal ectasia is keratoconus that occurs after refractive surgery. Both lead to functional loss of vision and the need for corneal transplantation.

Corneal Refractive Surgery

Corneal refractive surgery may be considered medically necessary when ANY ONE of the following is met:

• Correction of astigmatism resulting from trauma or from a previous eligible surgery (i.e., cataract surgery); or
• Correction of aphakia.

Corneal refractive surgery not meeting the criteria as indicated in this policy is considered not medically necessary.

NOTE: These procedures should not be confused with corneal transplants (also called keratoplasties). 

Phototherapeutic Keratectomy (PTK)

PTK may be considered medically necessary for ANY ONE of the following conditions: 

• Corneal scarring and opacities (including post-traumatic, post-infectious, post-surgical, and secondary to pathology); or
• Superficial corneal dystrophy (including granular, lattice and Reis-Bückler’s dystrophy); or
• Epithelial membrane dystrophy; or
• Irregular corneal surfaces due to Salzmann’s nodular degeneration or keratoconus nodule; or
• Recurrent corneal erosions when more conservative measures (i.e., lubricants, hypertonic saline, patching, bandage contact lenses, gentle debridement of severely aberrant epithelium) have failed to halt the erosions.

NOTE: PTK should not be confused with photorefractive keratectomy (PRK). Although technically the same procedure, PTK is used for the correction of particular corneal diseases whereas PRK involves the use of the excimer laser for correction of refractive errors (i.e.., myopia, hyperopia, astigmatism, and presbyopia) in persons with otherwise non-diseased corneas.  

PTK not meeting the criteria as indicated in this policy is considered not medically necessary.

Intrastromal Corneal Ring Segments

Implantation of intrastromal corneal ring segments may be considered medically necessary for the treatment of keratoconus in individuals 21 years of age or older who meet ALL the following criteria:

• Who have experienced a progressive deterioration in their vision, such that they can no longer achieve adequate functional vision on a daily basis with their contact lenses or spectacles; and
• Who have clear central corneas with a corneal thickness of 450 microns or greater at the proposed incision site; and
• Who have corneal transplantation as the only option remaining to improve their functional vision.

Insertion of intrastromal cornea ring segments not meeting the criteria as indicated in this policy is considered not medically necessary.

Any pre- and post-operative evaluations and measurements. not an all-inclusive list (i.e.., ophthalmic echography, keratometry, pachymetry) performed in conjunction with services identified with ineligible procedures are non-covered. 

Contact Lenses for Keratoconus

When a covered individual or group customer benefit, contact lenses are covered for the treatment of keratoconus.  

Corneal Collagen Cross-Linking

Corneal CXL using riboflavin and ultraviolet A may be considered medically necessary in individuals who have failed conservative treatment (i.e., spectacle correction, rigid contact lens) when used for EITHER of the following conditions:

• Progressive keratoconus: or 
• Corneal ectasia after refractive surgery.

Corneal CXL using riboflavin and ultraviolet A not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.