1.0 CPT 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) 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 United States (US) 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 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 code 67221) with Visudyne (Healthcare Common Procedure Coding
System (HCPCS) code 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 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 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 codes 0191T,
0474T, C1783, and L8612), and each additional insertion (CPT 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 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 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 code 92065).
5.5 Epikeratophakia for treatment
of aphakia and myopia is unproven.
5.6 Transpupillary thermotherapy
(CPT 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.