Endothelial Keratoplasty Form

Clinical Review Criteria Related to Endothelial Keratoplasty

Page 1 of 3 Effective 12/1/2022 (Date of Last Review: 9/13/2022) © 2014 Health New England Clinical Review Criteria Related to Endothelial Keratoplasty (also known as Posterior Lamellar Keratoplasty)

Definitions:

• Descemet's stripping endothelial keratoplasty (DSEK) - the member’s Descemet membrane is peeled off and is replaced with a partial thickness graft. Both donor and host cornea are manually dissected.
•
Descemet's stripping automated endothelial keratoplasty (DSAEK) is a partial thickness cornea transplant procedure that involves selective removal of the patient's Descemet membrane and endothelium, followed by transplantation of donor corneal endothelium in addition to donor corneal stroma. • Descemet's membrane endothelial keratoplasty (DMEK) is a partial thickness cornea transplant where the host Descemet membrane (DM) and endothelium are replaced by donor DM and endothelium.
• Descemet’s membrane automated endothelial keratoplasty (DMAEK) - only the damaged cell layer is replaced and the donor tissue used is only one cell layer in thickness.
• Descemet’s membrane: Transparent highly elastic thin layer of tissue that covers the inner surface of the cornea. It is lined with epithelium. • Keratoconus: Non-inflammatory eye condition where the normally round dome-shaped cornea begins to develop into a cone-like bulge caused by progressive thinning of the cornea. • Aphakia: Absence of the lens of the eye.
• Iridocorneal endothelial (ICE) syndrome: Syndrome consists of 3 main features: 1. Visible changes in the iris; 2. Swelling of the cornea; and 3. Development of glaucoma. Most common in women and usually present in only 1 eye. • Endothelial corneal dystrophy (Fuch’s dystrophy): Cells in the cornea’s inner layer gradually deteriorate with unknown cause. • Pellucid marginal degeneration: Clear bilateral thinning (ectasia) in the inferior and peripheral region of the cornea.

Policy:

I. Criteria for Approval: • Health New England has adopted InterQual criteria. • HNE Nurse Reviewers use InterQual. • InterQual criteria - available upon request by members and providers

II. Required Documentation: A. Clinical office notes from treating provider

CPT Codes: (Confirmed on 6/14/2022 both are on Y/N list.)

65756 Keratoplasty (corneal transplant); endothelial

65757 Backbench preparation of corneal endothelial allograft prior to transplantation.
(List separately in addition to code for primary procedure.)

Clinical Review Criteria Related to Endothelial Keratoplasty

Page 2 of 3 Effective 12/1/2022 (Date of Last Review: 9/13/2022) © 2014 Health New England

Medical Criteria Disclaimer:

Property of Health New England. All rights reserved. Health New England has adopted InterQual criteria that is an evidence-based clinical decision support solution to help payers, providers and government agencies make clinically appropriate medical utilization decisions. The medical criteria contain the applicable HCPCS codes, diagnoses, and accepted standards of practice and are consistent with Clinical Practice Guidelines. The Medical criteria are applied to each aspect of the prospective, concurrent or retrospective review processes.

Health New England Reviews and approves all InterQual criteria. Input from actively practicing physicians/ practitioners with relevant expertise is provided through the Utilization Management Committee and the Clinical Care Advisory Committee prior to being adopted by Health New England.

Each benefit program defines which services are covered. The conclusion that a particular service, testing or supply is medically necessary does not constitute a representation or warranty that this service, testing or supply is covered and/or paid for by Health New England, as some programs exclude coverage for services, testing or supplies that Health New England considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern.
In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare Advantage and Medicaid members. Health New England has adopted the herein policy in providing management, administrative and other services to its Health Plan.

REFERENCES:

NCQA Standard, UM2, Clinical Criteria for Utilization Management Decisions, Element A

Maier, P., Reinhard, T., & Cursiefen, C. (2013, May). Descemet stripping endothelial keratoplasty--rapid recovery of visual acuity, Retrieved April 25, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3679620/

Lee, W. B., Jacobs, D. S., Musch, D. C., Kaufman, S. C., Reinhart, W. J., & Shtein, R. M. (2009, September). Descemet's stripping endothelial keratoplasty: Safety and outcomes: A report by the American Academy of Ophthalmology, Retrieved April 25, 2022, from

https://www.ncbi.nlm.nih.gov/pubmed/19643492

Dapena, I., Ham, L., & Melles, G. R. (2009, July). Endothelial keratoplasty: DSEK/DSAEK or DMEK-- the thinner the better? Retrieved April 25, 2022, from

https://www.ncbi.nlm.nih.gov/pubmed/19417653

Endothelial Keratoplasty (DSEK & DMEK). (n.d.), Retrieved April 25, 2022, from http://www.cornea.org/Learning-Center/Cornea-Transplants/Endothelial-Keratoplasty.aspx

Arede, P. V. (Reviewed January 17, 2022). Descemet Stripping Endothelial Keratoplasty, Retrieved April 25, 2022, from

https://eyewiki.aao.org/Descemet_Stripping_Endothelial_Keratoplasty#Background

CMS.gov, Refractive Keratoplasty, NCD 80.7, Retrieved April 25, 2022, from:

https://www.cms.gov/medicare-coverage-database/details/ncd- details.aspx?NCDId=72&ncdver=1&SearchType=Advanced&CoverageSelection=Both&NCSelecti on=NCA%7cCAL%7cNCD%7cMEDCAC%7cTA%7cMCD&ArticleType=BC%7cSAD%7cRTC% 7cReg&PolicyType=Both&s=24&KeyWord=Keratoplasty&KeyWordLookUp=Title&KeyWordSea rchType=Exact&kq=true&bc=EAAAABAAAAAA&

Clinical Review Criteria Related to Endothelial Keratoplasty

Page 3 of 3 Effective 12/1/2022 (Date of Last Review: 9/13/2022) © 2014 Health New England

Corneal Transplants (October 27, 2020) Cincinnati Eye Institute, Retrieved April 25, 2022, from:

    https://www.cincinnatieye.com/corneal-diseases/corneal-transplants/

Marks, J, (Medically Reviewed June 21, 2021) Corneal Transplant Surgery: What You Need to Know, Retrieved April 25, 2022, from:

Corneal Transplant Surgery (Keratoplasty): What to Expect (webmd.com)

Date Policy Changes 7/2022 • No significant changes 7/2021 • No significant changes