Anthem Blue Cross ConnecticutCommercial Clinical Policy

Anthem Blue Cross Connecticut CG-SURG-94 Keratoprosthesis Form


Keratoprosthesis using the Dohlman Doane Boston KPro

Indications

(773200) Is the cornea severely opaque and vascularized, AND is there documentation of at least one prior failed corneal transplant procedure? 
(773201) Is there documentation of a condition predisposing the individual to a high likelihood of corneal transplant failure, such as an autoimmune condition with ocular involvement or heavily vascularized corneal scars? 
(773202) Does the patient have limbal stem cell compromise, mucus membrane pemphigoid, neuropathic keratopathy, ocular chemical burns, ocular cicatricial pemphigoid, postherpetic anesthesia, severe dry eye, or Stevens-Johnson Syndrome? 

Keratoprosthesis procedures using an artificial cornea device other than the Boston KPro

Notes: Only the Boston KPro device is considered medically necessary.


Contraindications

(773203) Is the artificial cornea device being used for keratoprosthesis not the Boston KPro? 

All other indications for keratoprosthesis procedures not listed

Notes: Keratoprosthesis procedures are not medically necessary for indications not specifically listed as medically necessary.


Contraindications

(773204) Are all reasons for keratoprosthesis outside the listed medically necessary conditions? 
Effective Date

01/03/2024

Last Reviewed

11/09/2023

Original Document

  Reference



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.