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TRICARE Policy Manual 6010.60-M, April 1, 2015
Chapter 4
Section 21.1
Eye And Ocular Adnexa
Issue Date:  August 26, 1985
Authority:  32 CFR 199.4(c)(2), (c)(3) and (g)(46)
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Revision:  C-29, August 9, 2018
1.0  CPT PROCEDURE CODES
0100T, 0191T, 0253T, 0308T, 0376T, 0402T, 0472T - 0474T, 65091 - 65755, 65772 - 66175, 66179 - 68899, 77600 - 77615
2.0  HCPCS PROCEDURE CODES
C1783, L8612
3.0  DESCRIPTION
The eye is the organ of vision and the ocular adnexa are the appendages or adjunct parts; i.e., eyelids, lacrimal apparatus.
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).
5.2  Eyeglasses, and contact lenses except as noted in Chapter 7, Section 6.2.
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.
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