Does 65785 require prior authorization?

Yes, 65785 requires prior authorization (medium confidence). Conditional coverage; review criteria to confirm PA need.

What is the Medicare reimbursement rate for 65785?

Medicare facility rate: $386.11. Non-facility rate: $2098.58. Work RVU: 5.26.

HCPCS/CPT

Prior Auth Required

Conditional coverage; review criteria to confirm PA need (medium confidence)

Work RVU

5.26

Facility

$386.11

Non-Facility

$2098.58

For corneal relaxing incisions (CPT 65772): documentation of surgically-induced astigmatism ≥3.00 D, documentation that procedure is post-cataract or post-corneal transplant surgery, and documentation that the individual is intolerant of glasses or contact lenses.
For intrastromal corneal ring segments (CPT 65785) per HDE: documentation that the individual meets ALL HDE criteria: progressive deterioration in vision such that adequate functional vision on a daily basis with contact lenses or spectacles can no longer be achieved; age ≥21 years; clear central corneas; corneal thickness ≥450 microns at the proposed incision site (measurements recorded); and documentation that corneal transplantation is the only remaining option to improve functional vision.
Evidence that the intrastromal corneal ring segment implantation is performed in accordance with the FDA HDE specifications (device and indication alignment with HDE).

Corneal relaxing incision (CPT 65772) for correction of surgically-induced astigmatism of 3.00 diopters (D) or greater when performed post-cataract or post-corneal transplant surgery in an individual who is intolerant of glasses or contact lenses (considered medically necessary).
Insertion/implantation of intrastromal corneal ring segments (CPT 65785) when provided in accordance with the FDA Humanitarian Device Exemption (HDE) specifications (e.g., INTACS® prescription inserts) for treatment of myopia and astigmatism in individuals with keratoconus who meet ALL of the following criteria: progressive deterioration in vision such that adequate functional vision on a daily basis with contact lenses or spectacles can no longer be achieved; age 21 years or older; clear centra [...]
Correction of surgically induced astigmatism with a corneal relaxing incision or corneal wedge resection is consideredmedically necessarywhenallof the following criteria are met:
The astigmatism is the result of a previous cataract surgery, medically necessary refractive surgery, scleral buckling for retinal detachment, or corneal transplant;and
The degree of astigmatism is 3.00 diopters or greater;and
The medical record documents inadequate functional vision with any of the following: (1) contact lenses, (2) spectacles, or (3) contact lenses and spectacles.

CIGNA-0141 — Corneal Remodeling for Refractive Errors - (0141)

ANTHEM-CG-SURG-77 — CG-SURG-77 Refractive Surgery

Ask Verity about documentation requirements, denial risks, or coverage in your state.