00109
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- Increase of 1.00 D or more in manifest cylinder;or
- Increase of 0.50 D or more in manifest refraction spherical equivalent (MRSE);and
- Age 14 years or older;and
- Increase of 1.00 diopters (D) or more in the steepest keratometry measurement;or
- Corneal collagen cross-linking (CXL) is consideredmedically necessaryas a treatment for progressive keratoconus when all of the following conditions are met:
- Diagnosis of keratoconus based on keratometry and corneal mapping;and
1 Active Policy
ANTHEM-CG-SURG-105 — CG-SURG-105 Corneal Collagen Cross-Linking
Related Codes
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