00115
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- Keratoprosthesis using the Dohlman Doane Boston KPro (“Boston KPro”) device is consideredmedically necessaryfor the treatment of corneal blindness wheneitherof the following criteria are met (AorB):
- For individuals with prior corneal transplant:The cornea is severely opaque and vascularized;andThere is documentation of at least one prior failed corneal transplant procedure;or
- The cornea is severely opaque and vascularized;and
- There is documentation of at least one prior failed corneal transplant procedure;or
- There is documentation of the presence of a condition predisposing the individual to a high likelihood of corneal transplant failure, including but not limited toanyof the following:Autoimmune conditions with ocular involvement;orHeavily vascularized corneal scars;orLimbal stem cell compromise;orMucus membrane pemphigoid;orNeuropathic keratopathy;orOcular chemical burns;orOcular cicatricial pemphigoid;orPostherpetic anesthesia;orSevere dry eye;orStevens-Johnson Syndrome.
- Autoimmune conditions with ocular involvement;or
1 Active Policy
ANTHEM-CG-SURG-94 — CG-SURG-94 Keratoprosthesis
Related Codes
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