1.0 CPT PROCEDURE
CODES
0100T, 0191T,
0253T, 0308T, 0376T, 0402T, 0472T - 0474T, 65091 - 65755, 65772
- 66175, 66179 - 68899, 77600 - 77615
4.0 POLICY
4.1 Services
and supplies required in the diagnosis and treatment of illness
or injury involving the eye or ocular adnexa are covered.
4.2 Phototherapeutic
Keratectomy (PTK) is covered for corneal dystrophies.
4.3 Strabismus.
Surgical procedures and eye examinations to correct, treat, or diagnose
strabismus are covered.
4.4 Corneal
transplants. A corneal transplant (keratoplasty) is a covered surgical
procedure. Relaxing keratotomy to relieve astigmatism following
a corneal transplant is covered.
4.5 Transpupillary
thermotherapy (laser hyperthermia, Current Procedural Terminology
(CPT) procedure codes 77600 - 77615), with chemotherapy, is covered
for the treatment of retinoblastoma. See also
Chapter 5, Section 5.1.
4.6 Intrastromal
Corneal Ring Segments (Intacs®) is covered for U.S. Food and Drug
Administration (FDA) approved indications for beneficiaries with
keratoconus who meet all of the following criteria:
4.6.1 Are
unable to achieve adequate vision using lenses or spectacles; and
4.6.2 For
whom corneal transplant is the only remaining option. Coverage allowed
effective July 17, 2005.
4.7 The
Ex-PRESS Mini Glaucoma Shunt (CPT procedure code 66183) and other
FDA approved aqueous shuts or stents may be considered for cost-sharing
when they are used to reduce Intraocular Pressure (IOP) in the treatment
of glaucoma, that cannot be controlled effectively with medications.
4.8 Off-label
use of Photodynamic Therapy (CPT procedure code 67221) with Visudyne
(HCPCS J3396) may be considered for cost-sharing for the treatment
of retinal astrocytic hamartoma in Tuberous Sclerosis. The effective
date is February 1, 2008.
4.9 Transpupillary
thermotherapy (CPT procedure code 67299) with Plaque Radiotherapy (Brachytherapy)
is covered for the treatment of choroidal melanoma. See also
Chapter 5, Section 3.2.
4.10 Photodynamic
Therapy for the treatment of Central Serous Chorioretinopathy in
accordance with the TRICARE provisions for the treatment of rare
diseases.
4.11 Implantable Miniature Telescope (IMT) is
covered for FDA approved indications for beneficiaries with end-stage-related
macular degeneration.
4.12 Canaloplasty for the treatment of primary
open angle glaucoma (CPT procedure codes 66174 and 66175) is covered.
4.13 Insertion
of aqueous drainage device (iStent®, CyPass®) during cataract surgery
to reduce IOP in the treatment of glaucoma, initial insertion (CPT
procedure codes 0191T, 0474T, C1783, and L8612), and each additional
insertion (CPT procedure code 0376T).
4.14 Collagen
Cross-linking for the treatment of corneal ectasia due to the rare
disease Keratoconus is safe and effective and may be considered
for cost-sharing.
4.15 Insertion, programing
,
evaluation, and interrogation of retinal prosthesis
(CPT procedure codes 0472T and 0473T) is covered for use with Argus®
II Retinal Prosthesis System
(in accordance with the humanitarian
device policy, Chapter 8, Section 5.1).
5.0 EXCLUSIONS
5.1 Refractive
corneal surgery except as noted in
paragraph 4.4 (CPT procedure
codes 65760, 65765, 65767, 65770, 65771).
5.3 Orthokeratology.
5.4 Orthoptics,
also known as visual training, vision therapy, eye exercises, eye
therapy, is excluded by
32 CFR 199.4(g)(46) (CPT procedure code 92065).
5.5 Epikeratophakia
for treatment of aphakia and myopia is unproven.
5.6 Transpupillary
thermotherapy (CPT procedure code 67299) as primary treatment of
choroidal melanoma is unproven.
5.7 Autologous
serum eye drops for the treatment of dry eye syndrome, keratitis,
or ocular hypertension is unproven.
6.0 Effective Dates
6.1 April
1, 2011, coverage for Ex-PRESS Mini Glaucoma Shunt.
6.2 July
17, 2005 coverage for Intrastromal Corneal Ring Segments (Intacs®).
6.3 December
1, 2014, coverage for Photodynamic Therapy for Central Serous Chorioretinopathy.
6.4 February
14, 2015, coverage for Canaloplasty for the treatment of glaucoma.
6.5 June
17, 2015, coverage date for IMT.
6.6 October
7, 2015, coverage date for iStent®.
6.7 April
15, 2016, for Collagen Cross-linking for corneal ectasia due to
the rare disease Keratoconus.
6.8 July 29, 2016, for CyPass®.
6.9 January 1, 2017, for insertion
of retinal prosthesis.
6.10 August
1, 2017, for programming, evaluation, and interrogation of
retinal prosthesis.