Anthem Blue Cross Connecticut CG-SURG-94 Keratoprosthesis Form

This document addresses the permanent keratoprosthesis. This ocular device functions as an implanted artificial cornea intended to restore useful vision to individuals with severe corneal disease not amenable to conventional corneal transplantation.

Note: For information concerning other ophthalmic topics, see:

• SURG.00061 Presbyopia and Astigmatism-Correcting Intraocular Lenses
• CG-SURG-72 Endothelial Keratoplasty
• CG-SURG-77 Refractive Surgery

Clinical Indications

Medically Necessary:

Keratoprosthesis using the Dohlman Doane Boston KPro (“Boston KPro”) device is considered medically necessary for the treatment of corneal blindness when either of the following criteria are met (A or B):

1. For individuals with prior corneal transplant:
   1. The cornea is severely opaque and vascularized; and
   2. There is documentation of at least one prior failed corneal transplant procedure;
      or
2. There is documentation of the presence of a condition predisposing the individual to a high likelihood of corneal transplant failure, including but not limited to any of the following:
   1. Autoimmune conditions with ocular involvement; or
   2. Heavily vascularized corneal scars; or
   3. Limbal stem cell compromise; or
   4. Mucus membrane pemphigoid; or
   5. Neuropathic keratopathy; or
   6. Ocular chemical burns; or
   7. Ocular cicatricial pemphigoid; or
   8. Postherpetic anesthesia; or
   9. Severe dry eye; or
   10. Stevens-Johnson Syndrome.

Not Medically Necessary:

Keratoprosthesis procedures using an artificial cornea device other than the Boston KPro are considered not medically necessary.

Keratoprosthesis procedures are considered not medically necessary for all other indications not listed above as medically necessary.