Corneal transplants (keratoplasties) are performed as follows:
Corneal transplant may be considered medically necessary for ANY of the following indications:
Corneal transplants not meeting the criteria as indicated in this policy are considered not medically necessary.
65710 |
65730 |
65750 |
65755 |
|
|
|
Artificial Cornea
Keratoprosthesis using an United States Food and Drug Administration (U.S. FDA) approved device may be considered medically necessary when ALL of the following criteria are met:
The use of an artificial cornea device not meeting the criteria as indicated in this policy is considered not medically necessary.
65770 |
L8609 |
|
|
|
|
|
Endothelial Keratoplasty (DSEK, DSAEK, DMEK, DMAEK)
Endothelial keratoplasty including 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:
Endothelial keratoplasty not meeting the criteria as indicated in this policy is considered not medically necessary.
65756 |
65757 |
|
|
|
|
|
C1818 |
|
|
|
|
|
|
American Academy of Ophthalmology-2018
The 2018 Preferred Practice Parameter on ocular edema and opacification by the American Academy of Ophthalmology did not provide specific recommendations on the keratoprosthesis, but discussed the technology and its current use:
“Significant improvements in the design and postoperative management of the Boston type 1 keratoprosthesis has resulted in a steady rise in the number of these procedures performed both in the United States and abroad. Reduced incidence of postoperative stromal necrosis and bacterial endophthalmitis due to the chronic use of protective soft contact lenses and topical antibiotics has resulted in improved retention and visual outcomes and has had a positive impact on surgeons’ perceptions of when to recommend keratoprosthesis. Once considered a procedure of last resort in patients with severe bilateral visual impairment, it is now being used for a variety of unilateral and bilateral indications, such as ocular trauma, herpetic keratitis, aniridia, and Stevens-Johnson syndrome. More recently, as corneal surgeons have gained a greater appreciation of the failure rate of repeat corneal transplantation, a role for a keratoprosthetic in cases of multiple graft failure has become clearer. Despite earlier suggestions, keratoprosthetics are not considered ideal for pediatric cases, particularly as primary treatment.…
“Patients with severe dry eye and autoimmune ocular surface diseases...remain a difficult management group despite the other successes of the Boston type 1 keratoprosthetic. Primary placement of the Boston keratoprosthesis in this group of patients results in a higher rate of epithelial defects, scleral and corneal necrosis, extrusion, and endophthalmitis. Some surgeons advocate ocular surface reconstruction with combined keratolimbal allografts or living related allografts prior to placement of the keratoprosthesis. This can potentially lead to improved outcomes in this group. The Boston type 2 keratoprosthetic designed to be used through the eyelid and the osteo-odonto-keratoprosthesis have been implanted with some success in this group of patients.”
Covered Diagnosis Codes for Procedure Codes, 65710, 65730, 65750, 65755, 65756, 65757, 65770, C1818, and L8609
B60.13 |
H16.001 |
H16.002 |
H16.003 |
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 |
H18.501 |
H18.502 |
H18.503 |
H18.511 |
H18.512 |
H18.513 |
H18.521 |
H18.522 |
H18.523 |
H18.531 |
H18.532 |
H18.533 |
H18.541 |
H18.542 |
H18.543 |
H18.551 |
H18.552 |
H18.553 |
H18.591 |
H18.592 |
H18.593 |
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 |
H55.82 |
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 |
S05.61XA |
S05.62XA |
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 |
T49.5X5A |
T49.5X5D |
T49.5X5S |
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 |
T86.8401 |
T86.8402 |
T86.8403 |
T86.8411 |
T86.8412 |
T86.8413 |
T86.8421 |
T86.8422 |
T86.8423 |
T86.8481 |
T86.8482 |
T86.8483 |
T86.8491 |
T86.8492 |
T86.8493 |
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, and subject to the applicable laws of your state.
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:
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.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
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:
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.