CG-SURG-94 Keratoprosthesis

This policy addresses keratoprosthesis with the Dohlman-Doane Boston Keratoprosthesis (Boston KPro) for treating corneal blindness. It is covered when the cornea is severely opaque and vascularized and either there is at least one prior failed corneal transplant or a high risk of graft failure due to conditions such as autoimmune ocular disease, heavily vascularized scars, limbal stem cell deficiency, chemical burns, severe dry eye, ocular cicatricial pemphigoid, postherpetic anesthesia, neuropathic keratopathy, mucus membrane pemphigoid, or Stevens-Johnson syndrome. Keratoprosthesis using any artificial cornea other than the Boston KPro, or for any other indications, is not medically necessary.

"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):"