65781
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
17.69
Facility
$1122.94
Non-Facility
$1122.94
Documentation Required
- For allo-limbal transplants or allogeneic corneal epithelial stem cell transplantation: documentation of donor source (living-related, cadaver), HLA matching if applicable, and planned systemic immunosuppression regimen and monitoring.
- For autologous ex-vivo expanded limbal epithelial transplantation: documentation of donor biopsy site, cell culture method and characteristics (e.g., percentage of p63-bright holoclone-forming stem cells) when available and pertinent to prognosis.
- Pre-procedure clinical notes describing indication, prior failed therapies, risks/benefits discussed, and informed consent.
- Post-operative follow-up documentation: epithelialization status, pain/symptom relief, visual acuity measurements, graft integrity, and any adverse events (e.g., infection, graft rejection, extrusion).
Key Coverage Criteria
- Aniridia (hereditary)
- Corneal limbal dermoid
- Limbal stem cell transplantation for gelatinous drop-like corneal dystrophy
- Neuropathic corneal pain
- Tube erosion (double-layer amniotic membrane technique)
- Management of ocular surface and orbital disorders (using ProKera/sutureless devices)
1 Active Policy
AETNA-CPB-0293 — Corneal Graft and Amniotic Membrane Transplantation, Corneal Stromal Lenticule Transplantation, Limbal Stem Cell Transplantation, or Sural Nerve Grafting for Ocular Indications
Related Codes
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