CG-SURG-77 Refractive Surgery

This policy addresses refractive eye surgeries, including corneal relaxing incisions/wedge resections and laser procedures (LASIK, LASEK, PRK/PARK). Coverage is medically necessary only to correct surgically induced astigmatism ≥3.00 diopters caused by prior cataract surgery, medically necessary refractive surgery, scleral buckling, or corneal transplant, with documented inadequate functional vision despite spectacles and/or contact lenses (and when all other policy criteria for the selected laser procedure are met). All other uses of these procedures—including LASIK/LASEK, epikeratoplasty, and corneal relaxing incisions/wedge resections outside this subset—are considered not medically necessary.

"Correction of surgically induced astigmatism with a corneal relaxing incision or corneal wedge resection is consideredmedically necessarywhenallof the following criteria are met:"