Anthem Blue Cross Connecticut CG-SURG-105 Corneal Collagen Cross-Linking Form

This document addresses corneal collagen cross-linking (CXL, also known as 3-CR or C3R), a photochemical treatment of progressive keratoconus and other corneal thinning processes, such as ectasia after laser in-situ keratomileusis (LASIK).

Note: Please see the following related documents for additional information:

• CG-SURG-72 Endothelial Keratoplasty
• CG-SURG-77 Refractive Surgery

Clinical Indications

Medically Necessary:

Corneal collagen cross-linking (CXL) is considered medically necessary as a treatment for progressive keratoconus when all of the following conditions are met:

1. Diagnosis of keratoconus based on keratometry and corneal mapping; and
2. Any of the following changes have occurred within 24 months:
   1. increase of 1.00 diopters (D) or more in the steepest keratometry measurement; or
   2. increase of 1.00 D or more in manifest cylinder; or
   3. increase of 0.50 D or more in manifest refraction spherical equivalent (MRSE); and
3. Age 14 years or older; and
4. Corrected distance visual acuity (CDVA) worse than 20/20 with properly fitted spectacles or contact lenses; and
5. Corneal thickness 300 microns or more; and
6. No history of corneal or systemic disease that would interfere with healing after the procedure such as chemical injury or delayed epithelial healing in the past.

Corneal collagen cross-linking (CXL) is considered medically necessary as a treatment for corneal ectasia resulting from refractive surgery (e.g. LASIK) when all of the following conditions are met:

1. Age 14 years of age or older; and
2. Axial topography pattern consistent with corneal ectasia; and
3. Corrected distance visual acuity (CDVA) worse than 20/20; and
4. Corneal thickness of at least 300 microns at the thinnest area; and
5. No history of corneal or systemic disease that would interfere with healing after the procedure such as chemical injury or delayed epithelial healing in the past.

Not Medically Necessary:

Corneal collagen cross-linking (CXL) is considered not medically necessary when the above criteria have not been met and for all other indications.