J2787 — Riboflavin 5'-phosphate, ophthalmic solution, up to 3 ml
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Evidence of progression such as changes in refraction, visual acuity, or corneal shape
- Objective documentation of progression (for example, an increase of ≥1.0 diopter in the steepest keratometry value)
- Subjective manifest refraction documenting the specified change in astigmatism (≥1.0 D) or spherical equivalent (≥0.50 D).
- Measurement documentation of back optical zone radius showing a decrease ≥0.1 mm for rigid contact lens wearers when other data are unavailable.
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
6 Active Policies
ANTHEM-CG-SURG-105 — CG-SURG-105 Corneal Collagen Cross-Linking
BCBSIL-OTH903.028 — Corneal Collagen Cross-Linking
BCBSMT-OTH903.028 — Corneal Collagen Cross-Linking
BCBSNM-OTH903.028 — Corneal Collagen Cross-Linking
BCBSOK-OTH903.028 — Corneal Collagen Cross-Linking
Related Codes
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