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.