Anthem Blue Cross Connecticut CG-SURG-77 Refractive Surgery Form

This document addresses refractive surgeries which refers to various surgical procedures performed to correct refractive errors of the eye.

Note: This document does not address PTK (phototherapeutic keratotomy) which refers to procedures to correct disorders of the cornea.

For information concerning related topics, see:

• SURG.00061 Presbyopia and Astigmatism-Correcting Intraocular Lenses
• CG-SURG-72 Endothelial Keratoplasty
• CG-SURG-94 Keratoprosthesis
• CG-SURG-105 Corneal Collagen Cross-Linking

Clinical Indications

Medically Necessary:

Correction of surgically induced astigmatism with a corneal relaxing incision or corneal wedge resection is considered medically necessary when all of the following criteria are met:

1. The astigmatism is the result of a previous cataract surgery, medically necessary refractive surgery, scleral buckling for retinal detachment, or corneal transplant; and
2. The degree of astigmatism is 3.00 diopters or greater; and
3. The medical record documents inadequate functional vision with any of the following: (1) contact lenses, (2) spectacles, or (3) contact lenses and spectacles.

Laser in-situ keratomileusis (LASIK), laser epithelial keratomileusis (LASEK), photorefractive keratectomy (PRK), and photoastigmatic keratectomy (PARK or PRK-A) are considered medically necessary when all of the following are met:

1. Prior cataract, corneal, or scleral buckling surgery for retinal detachment has been performed on this eye; and
2. The medical record documents symptoms due to aniseikonia (different sizes of ocular images) or anisometropia (difference in power of refraction); and
3. The medical record documents inadequate functional vision with any of the following: (1) contact lenses, (2) spectacles, or (3) contact lenses and spectacles; and
4. The post-operative spherical equivalent refractive error has changed by 3 diopters when compared to the preoperative refractive error or the degree of astigmatism is 3 diopters or greater.

Small incision lenticule extraction (SMILE) is considered medically necessary when all of the following criteria are met:

1. Prior cataract, corneal, or scleral buckling surgery for retinal detachment has been performed on this eye; and
2. The medical record documents symptoms due to aniseikonia (different sizes of ocular images) or anisometropia (difference in power of refraction); and
3. The medical record documents inadequate functional vision with any of the following: (1) contact lenses, (2) spectacles, or (3) contact lenses and spectacles; and
4. The post-operative spherical equivalent refractive error has changed by 3 diopters when compared to the preoperative refractive error; and the following refractive error exists:
   1. Spherical refractive error (in minus cylinder format): from -1.00 diopters through –10.00 diopters; and
   2. Cylinder (when astigmatism is present): from -0.75 diopters through -3.00 diopters; and
   3. Refraction spherical equivalent: less than or equal to 10.00 diopters.

Epikeratoplasty (epikeratophakia) is considered medically necessary for either of the following conditions:

1. Correction of refractive errors of acquired or congenital aphakia; or
2. Hypermetropia following cataract surgery in individuals unable to receive intraocular lens.

Implantation of intrastromal corneal ring segments (INTACS^™ Prescription Inserts, Addition Technology, Sunnyvale, CA) is considered medically necessary in individuals with keratoconus who meet all of the following criteria:

1. Progressive deterioration in vision, such that individuals can no longer achieve adequate functional vision on a daily basis with either contact lenses or spectacles; and
2. 21 years of age or older; and
3. Presence of clear central cornea; and
4. Corneal thickness of 450 microns or greater at the proposed incision site; and
5. Who have corneal transplantation as the only remaining option to improve their functional vision.

Not Medically Necessary:

Procedures considered not medically necessary include, but are not limited to, the following:

1. Correction of surgically induced astigmatism with a corneal relaxing incision or corneal wedge resection, except for the small subset of individuals noted above;
2. Laser in-situ keratomileusis (LASIK), except for the small subset of individuals noted above;
3. Laser epithelial keratomileusis (LASEK), except for the small subset of individuals noted above;
4. Epikeratoplasty (epikeratophakia), except for the small subset of individuals as noted above;
5. Laser thermal keratoplasty (LTK);
6. Photorefractive keratectomy (PRK) and photoastigmatic keratectomy (PARK or PRK-A), except for the small subset of individuals noted above;
7. Small incision lenticule extraction (SMILE) except for the small subset of individuals noted above;
8. Radial keratotomy and its variants;
9. Implantable contact lenses without lens extraction (phakic intraocular lenses) including, but not limited to, Artisan^® Phakic Intraocular Lens also known as Verisyse^™ Phakic Intraocular Lens (Ophtec USA, Inc., Boca Raton, FL) and Visian^™ ICL Implantable Collamer Lens (Starr Surgical Company, Monravia, CA);
10. Clear lens extraction (CLE) with or without implantation of an accommodating or nonaccommodating lens;
11. Implantation of intrastromal corneal ring segments (INTACS) for the correction of myopia;
12. Conductive keratoplasty to treat presbyopia (that is, ViewPoint^™ CK System [Refracrtec Inc., Irvine, CA]);
13. Keratophakia;
14. Orthokeratology;
15. Standard keratomileusis.