Anthem Blue Cross Connecticut CG-SURG-105 Corneal Collagen Cross-Linking Form
This procedure is not covered
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:
- Diagnosis of keratoconus based on keratometry and corneal mapping; and
- Any of the following changes have occurred within 24 months:
- increase of 1.00 diopters (D) or more in the steepest keratometry measurement; or
- increase of 1.00 D or more in manifest cylinder; or
- increase of 0.50 D or more in manifest refraction spherical equivalent (MRSE); and
- Age 14 years or older; and
- Corrected distance visual acuity (CDVA) worse than 20/20 with properly fitted spectacles or contact lenses; and
- Corneal thickness 300 microns or more; and
- 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:
- Age 14 years of age or older; and
- Axial topography pattern consistent with corneal ectasia; and
- Corrected distance visual acuity (CDVA) worse than 20/20; and
- Corneal thickness of at least 300 microns at the thinnest area; and
- 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.