C1818 — Integrated keratoprosthesis
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documentation of prior failed cadaveric corneal transplant(s) or clinical rationale showing cadaveric transplant has a very low likelihood of success.
- Documentation of visual acuity/function of the contralateral eye and assessment of likelihood of meaningful visual improvement.
- Documentation that the procedure will be performed at a center experienced in keratoprosthesis care and by a surgeon trained in implantation techniques.
- Clinical documentation of corneal opacity and vascularization (exam notes, imaging as available).
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
6 Active Policies
ANTHEM-CG-SURG-94 — CG-SURG-94 Keratoprosthesis
BCBSIL-OTH903.030 — Keratoprosthesis
BCBSMT-OTH903.030 — Keratoprosthesis
BCBSNM-OTH903.030 — Keratoprosthesis
BCBSOK-OTH903.030 — Keratoprosthesis
Related Codes
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