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The established surgical treatment for corneal disease is penetrating keratoplasty (PK), which involves the creation of a large central opening through the cornea and then filling the opening with full-thickness donor cornea that is sutured in place. Visual recovery after PK may take 1 year or more due to slow wound healing of the avascular full-thickness incision, and the procedure frequently results in irregular astigmatism due to sutures and the full-thickness vertical corneal wound. PK is associated with an increased risk of wound dehiscence, endophthalmitis, and total visual loss after relatively minor trauma for years after the index procedure. There is also the risk of severe, sight-threatening complications such as expulsive suprachoroidal hemorrhage, in which the ocular contents are expelled during the operative procedure, as well as postoperative catastrophic wound failure.
A number of related techniques have been, or are being, developed to selectively replace the diseased endothelial layer. Endothelial keratoplasty, also referred to as posterior lamellar keratoplasty, is a form of corneal transplantation in which the diseased inner layer of the cornea, the endothelium, is replaced with healthy donor tissue. Specific techniques include Descemet stripping endothelial keratoplasty (DSEK), Descemet stripping automated endothelial keratoplasty (DSAEK), Descemet membrane endothelial keratoplasty (DMEK), and Descemet membrane automated endothelial keratoplasty (DMAEK). Endothelial keratoplasty, and particularly DSEK, DSAEK, DMEK, and DMAEK, are becoming standard procedures. Femtosecond laser-assisted endothelial keratoplasty (FLEK) and femtosecond and excimer laser-assisted endothelial keratoplasty (FELEK) have also been reported as alternatives to prepare the donor endothelium.
Definitions
The Descemet membrane is a thin, elastic and transparent layer of tissue that covers the inner surface of the cornea and protects the cornea from invasive material.
Pseudophakic bullous keratopathy (PBK) and aphakic bullous keratopathy (ABK) are types of corneal edema that may result from complications of cataract surgery.
The corneal epithelium is a single layer of cells on the inner surface of the cornea.
I. Endothelial keratoplasty (Descemet stripping endothelial keratoplasty, Descemet stripping automated endothelial keratoplasty, Descemet membrane endothelial keratoplasty [DMEK], or Descemet membrane automated endothelial keratoplasty) may be considered MEDICALLY NECESSARY AND APPROPRIATE for the treatment of endothelial failure. Causes include but are not limited to:
II. Endothelial keratoplasty is NOT MEDICALLY NECESSARY when endothelial dysfunction is not the primary cause of decreased corneal clarity, including but not limited to keratoconus.
III. Femtosecond laser-assisted endothelial keratoplasty (FLEK) or femtosecond and excimer laser-assisted endothelial keratoplasty (FELEK) are considered EXPERIMENTAL/INVESTIGATIVE for all indications due to the lack of clinical evidence demonstrating an impact on improved health outcomes.
Documentation Submission
Link to Pre-Authorization Form: https://www.bluecrossmn.com/sites/default/files/DAM/2021-12/BCBSMN-Pre-Auth-Request-fillable-X18509R07.pdf
No additional statements.
Blue Cross and Blue Shield of Minnesota medical policies apply generally to all Blue Cross and Blue Plus plans and products. Benefit plans vary in coverage and some plans may not provide coverage for certain services addressed in the medical policies. When determining coverage, reference the member’s specific benefit plan, including exclusions and limitations.
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Blue Cross and Blue Shield of Minnesota reserves the right to revise, update and/or add to its medical policies at any time without notice. Codes listed on this policy are included for informational purposes only and are subject to change without notice. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement.
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Acknowledgements:
CPT® codes copyright American Medical Association® 2022. All rights reserved.
CDT codes copyright American Dental Association® 2022. All rights reserved.
