HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
S-116-016
Topic:
Corneal Transplantation
Section:
Surgery
Effective Date:
October 1, 2017
Issued Date:
February 11, 2019
Last Revision Date:
January 2019
Annual Review:
January 2019
 
 

Corneal transplants (keratoplasties) are performed as follows:

  • Lamellar keratoplasty (LK), a partial thickness or penetrating keratoplasty (PK), full thickness cornea is removed and replaced with a donor cornea.
  • Endothelial keratoplasty (EK, DSEK, DSAEK,DMEK, posterior lamellar keratoplasty) - the diseased inner layer of the cornea, the endothelium, is removed and replaced with healthy donor tissue while keeping the anterior corneal surface intact.
Policy Position

Corneal transplantation may be considered medically necessary for ANY of the following indications:

  • Pseudophakic corneal edema; or
  • Aphakic corneal edema; or
  • Stromal corneal dystrophies; or
  • Primary corneal endotheliopathies; or
  • Ectasias/thinnings; or
  • Congenital opacities; or
  • Viral/post-viral keratitis; or
  • Microbial/post-microbial keratitis; or
  • Noninfectious ulcerative keratitis or perforation; or
  • Corneal degenerations; or
  • Chemical injuries; or
  • Regraft related to allograft rejection; or
  • Regraft unrelated to allograft rejection; or
  • Steven-Johnson Syndrome; or
  • Stromal corneal dystrophies; or
  • Trauma or injuries that cause corneal scarring; or
  • Viral/post-viral keratitis

Corneal transplantation is considered not medically necessary for indications other than those listed above.

65710

65730

65750

65755

 

 

 




Boston KPro - Artificial Cornea

Keratoprosthesis using the Dohlman Doane Boston KPro ("Boston KPro") device may be considered medically necessary when ALL of the following criteria are met:

  • The cornea is severely opaque and vascularized; and
  • Cadaveric corneal transplants have failed or there is a very low likelihood of success.

The use of any other artificial cornea device other than the Boston KPro is considered experimental/investigational and, therefore, non-covered because the safety and/or effectiveness of this services cannot be established by the available peer-reviewed literature.

65770

L8609

 

 

 

 

 




Endothelial Keratoplasty (DSEK, DSAEK, DMEK, DMAEK)

Endothelial keratoplasty (Descemet stripping endothelial keratoplasty [DSEK]), Descemet stripping automated endothelial keratoplasty (DSAEK), Descemet membrane endothelial keratoplasty (DMEK), or Descemet membrane automated endothelial keratoplasty (DMAEK) may be considered medically necessary for the treatment of endothelial dysfunction, including but not limited to ANY of the following indications:

  • Ruptures in Descemet membrane; or
  • Endothelial dystrophy; or
  • Aphakic, and pseudophakic bullous keratopathy; or
  • Iridocorneal endothelial (ICE) syndrome; or
  • Corneal edema attributed to endothelial failure; and
  • Failure or rejection of a previous corneal transplant. 

Endothelial keratoplasty for any indication other than listed above is considered experimental/investigational and, therefore, non-covered because the safety and/or effectiveness of this services cannot be established by the available peer-reviewed literature.

65756

65757

 

 

 

 

 




Femtosecond Laser-Assisted Corneal Endothelial Keratoplasty (FLEK)

FLEK or femtosecond and excimer laser assisted endothelial keratoplasty (FELEK) are considered experimental/investigational and, therefore, non-covered because the safety and/or effectiveness of this services cannot be established by the available peer-reviewed literature.

0289T

0290T

 

 

 

 

 



C1818

 

 

 

 

 

 




Related Policies

Refer to medical policy S-12 Team Surgery for additional information.


Covered Diagnosis Codes for Procedure Codes C1818, 65710, 65730, 65750, 65755, 65770, 65756, 65757, and L8609

B60.13

H16.001

H16.002

H16.003

H16.009

H16.011

H16.012

H16.013

H16.021

H16.022

H16.023

H16.031

H16.032

H16.033

H16.041

H16.042

H16.043

H16.051

H16.052

H16.053

H16.061

H16.062

H16.063

H16.071

H16.072

H16.073

H16.101

H16.102

H16.103

H16.111

H16.112

H16.113

H16.121

H16.122

H16.123

H16.131

H16.132

H16.133

H16.141

H16.142

H16.143

H16.201

H16.202

H16.203

H16.211

H16.212

H16.213

H16.221

H16.222

H16.223

H16.231

H16.232

H16.233

H16.251

H16.252

H16.253

H16.261

H16.262

H16.263

H16.291

H16.292

H16.293

H16.301

H16.302

H16.303

H16.311

H16.312

H16.313

H16.321

H16.322

H16.323

H16.331

H16.332

H16.333

H16.391

H16.392

H16.393

H16.401

H16.402

H16.403

H16.411

H16.412

H16.413

H16.421

H16.422

H16.423

H16.431

H16.432

H16.433

H16.441

H16.442

H16.443

H16.8

H16.9

H17.01

H17.02

H17.03

H17.11

H17.12

H17.13

H17.811

H17.812

H17.813

H17.821

H17.822

H17.823

H17.89

H17.9

H18.001

H18.002

H18.003

H18.011

H18.012

H18.013

H18.021

H18.022

H18.023

H18.031

H18.032

H18.033

H18.051

H18.052

H18.053

H18.061

H18.062

H18.063

H18.11

H18.12

H18.13

H18.20

H18.211

H18.212

H18.213

H18.221

H18.222

H18.223

H18.231

H18.232

H18.233

H18.30

H18.311

H18.312

H18.313

H18.321

H18.322

H18.323

H18.331

H18.332

H18.333

H18.40

H18.411

H18.412

H18.413

H18.421

H18.422

H18.423

H18.43

H18.441

H18.442

H18.443

H18.451

H18.452

H18.453

H18.461

H18.462

H18.463

H18.49

H18.50

H18.51

H18.52

H18.53

H18.54

H18.55

H18.59

H18.601

H18.602

H18.603

H18.611

H18.612

H18.613

H18.621

H18.622

H18.623

H18.70

H18.711

H18.712

H18.713

H18.721

H18.722

H18.723

H18.731

H18.732

H18.733

H18.791

H18.792

H18.793

H18.811

H18.812

H18.813

H18.821

H18.822

H18.823

H18.831

H18.832

H18.833

H18.891

H18.892

H18.893

H18.9

H54.0X33

H54.0X34

H54.0X35

H54.0X43

H54.0X44

H54.0X45

H54.0X53

H54.0X54

H54.0X55

H54.1131

H54.1132

H54.1141

H54.1142

H54.1151

H54.1152

H54.1213

H54.1214

H54.1215

H54.1223

H54.1224

H54.1225

H54.2X11

H54.2X12

H54.2X21

H54.2X22

H54.3

H54.413A

H54.414A

H54.415A

H54.42A3

H54.42A4

H54.42A5

H54.511A

H54.512A

H54.52A1

H54.52A2

H54.7

H54.8

L51.1

Q12.0

Q12.1

Q12.2

Q12.3

Q12.4

Q12.8

Q12.9

S05.21XA

S05.22XA

S05.31XA

S05.32XA

S05.51XA

S05.52XA

S05.60XA

S05.61XA

S05.62XA

S05.70XA

S05.71XA

S05.72XA

S05.8X1A

S05.8X2A

S05.8X9A

S05.91XA

S05.92XA

T26.11XA

T26.11XD

T26.11XS

T26.12XA

T26.12XD

T26.12XS

T49.4X5A

T49.4X5S

T49.5X5A

T49.5X5S

T85.21XA

T85.22XA

T85.29XA

T85.29XD

T85.29XS

T85.390A

T85.390D

T85.390S

T85.391A

T85.391D

T85.391S

T85.398A

T85.398D

T85.398S

T85.79XA

T85.79XD

T85.79XS

T85.818A

T85.818D

T85.818S

T85.820A

T85.820D

T85.820S

T85.828A

T85.828D

T85.828S

T85.830A

T85.830D

T85.830S

T85.838A

T85.838D

T85.838S

T85.840A

T85.840D

T85.840S

T85.848A

T85.848D

T85.848S

T85.850A

T85.850D

T85.850S

T85.858A

T85.858D

T85.858S

T85.860A

T85.860D

T85.860S

T85.868A

T85.868D

T85.868S

T85.890A

T85.890D

T85.890S

T85.898A

T85.898D

T85.898S

T86.840

T86.841

T86.842

T86.848

T86.849



Place of Service: Inpatient/Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

Corneal Transplantation is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.


The policy position applies to all commercial lines of business



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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
  • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

    Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.