Anthem Blue Cross Connecticut CG-SURG-72 Endothelial Keratoplasty Form

This document addresses a variety of endothelial keratoplasty (EK) techniques, also known as posterior lamellar keratoplasty, used to treat conditions affecting the cornea. The available EK procedures include: Descemet’s membrane endothelial keratoplasty (DMEK), Descemet’s stripping endothelial keratoplasty (DSEK), Descemet’s stripping automated endothelial keratoplasty (DSAEK) and Descemet’s membrane automated endothelial keratoplasty (DMAEK). Other similar procedures addressed in this document include Femtosecond Laser-Assisted Corneal Endothelial Keratoplasty (FLEK or FLAK) or Femtosecond and Excimer Lasers-Assisted Endothelial Keratoplasty (FELEK). These procedures differ from each other in the manner in which the recipient’s endothelium is removed and the methods used to prepare the donor tissue.

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

• CG-SURG-77 Refractive Surgery
• CG-SURG-94 Keratoprosthesis
• CG-SURG-105 Corneal Collagen Cross-Linking

Clinical Indications

Medically Necessary:

The use of DMEK, DSEK, DSAEK and DMAEK, is considered medically necessary for the treatment of disorders of the corneal endothelium, including but not limited to the following:

1. Fuchs’ endothelial dystrophy;
2. Aphakic and pseudophakic bullous keratopathy (corneal edema following cataract extraction);
3. Failure or rejection of a previous corneal transplant.

Not Medically Necessary:

The use of DMEK, DSEK, DSAEK and DMAEK is considered not medically necessary to treat disease or injury of the corneal stroma (for example, keratoconus, corneal ulcers caused by infection and traumatic corneal injuries).

The use of FLEK or FELEK is considered not medically necessary for all indications.