Prior Authorization Review Panel MCO Policy Submission
A separate copy of this form must accompany each policy submitted for review. Policies submitted without this form will not be considered for review.
Plan: Aetna Better Health Submission Date:04/01/2020
Policy Number: 0130 Effective Date: Revision Date: 04/09/2019
Policy Name: Computerized Corneal Topography
Type of Submission – Check all that apply:
New Policy Revised Policy*Annual Review – No Revisions Statewide PDL
*All revisions to the policy must be highlighted using track changes throughout the document.
Please prov ide a ny c larifying information for the p olicy be low:
CPB 0130 Computerized Corneal Topography
Clinical content was last revised on 04/09/2019. No additional non-clinical updates were made by Corporate since the last PARP submission.
Name of Authorized Individual (Please type or print):
Dr. Bernard Lewin, M.D.
Signature of Authorized Individual:
Revised July 22, 2019 Proprietary
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Computerized Corneal Topography - Medical Clinical Policy Bulletins | Aetna
(https://www.aetna.com/)
Computerized Corneal Topography
Last Review
04/09/2019
Effective: 05/06/1996
Next Review: 01/23/2020
R eview History
Definitions
Additional Information
C linical Policy Bulletin
Notes
Number: 0130
Policy
*Please see amendment forPennsylvaniaMedicaid
at the end of this CPB.
I. Aetna considers computerized corneal topography medically
necessary for any of the following conditions:
Central corneal ulcer; or
Corneal dystrophy, bullous keratopathy and complications of
transplanted cornea; or
Diagnosing and monitoring disease progression in keratoconus or
Terrien's marginal degeneration; or
Difficult fitting of contact lens (see
CPB 0126 - Contact Lenses and Eyeglasses (0126.html)) *; or
Post-traumatic corneal scarring; or
Pre- and post-penetrating keratoplasty and post kerato-refractive
surgery for irregular astigmatism (subject to medical necessity
criteria for these procedures - see
CPB 0023 - Corneal Remodeling (../1_99/0023.html)); or
Pterygium or pseudo pterygium.
* Generally, 1 testing for each eye is sufficient for fitting, unless
there is some reason for repeat testing conducted in the medical
record, such as a change in the member's condition from the prior
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examination. Repeat testing to monitor disease progression in
keratoconus or Terrien's marginal degeneration may be necessary
over time.
II. Note: Aetna does not c over c orneal topography if it is performed
pre- or post-operatively in relation to a non-covered pr ocedure
(i.e., refractive eye surgery). Most Aetna benefit plans exclude
coverage of refractive surgery. Please check benefit plan
descriptions for details.
III. Aetna considers corneal topography experimental and
investigational if it is performed as part of pre-operative
assessment of members with cataracts (see
CPB 0508 - Cataract Removal Surgery (../500_599/0508.html)).
IV. Aetna considers corneal topography experimental and
investigational for the management of members with the following
indications (not an all-inclusive list) because corneal topography
has not been shown to alter the clinical management of these
conditions such that clinical outcomes are improved.
Acanthomoeba keratitis
Accommodative disorders
Diplopia
Epithelial ingrowth following laser in situ keratomileusis (LASIK)
Interstitial keratitis
Kerato-conjunctivitis sicca
Lattice degeneration of retina
Lens subluxation (e.g., in Marfan syndrome)
Limbal dermoids
Microphthalmia
Nodular d egeneration of the cornea ( e.g., Salzmann's corneal
degeneration)
Ocular graft-versus-host disease
Open-angle glaucoma
Post-herpes simplex virus scarring of cornea
Refractive errors
Superficial punctate keratopathy.
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Computerized corneal topography (also known as computer assisted
corneal topography, computer assisted keratography, or
videokeratography) is a computer- assisted diagnostic technique in which
a special instrument projects a series of light rings on the cornea, creating
a color-coded map of the corneal surface as well as a cross-section
profile. This test is used for the detection of subtle corneal surface
irregularities and astigmatism as an alternative to manual keratometry.
The American Academy of Ophthalmology’s guidelines on “Primary open-
angle glaucoma” (AAO, 2010) mentioned no role for corneal topography
in the management of patients with open-angleglaucoma.
Choi and Kim (2012) examined the longitudinal changes in corneal
topographic indices over time in patients with mild keratoconus (KC) and
determined predictive factors for the increase in corneal curvature. These
investigators retrospectively reviewed the data of 94 eyes of patients with
mild KC who had undergone computerized video-keratography (Orbscan
IIz; Bausch & Lomb Surgical, Rochester, NY) at least twice at an interval
of greater than or equal to 1 year. Patients with an increase of greater
than or equal to 1.50 diopters (D) in the central keratometry (K) were
placed in the progression group, and the others were placed in the non-
progression group. In each group, the quantitative topographic
parameters were compared and tested as predictive factors for KC
progression. Additionally, corneal astigmatic changes were evaluated by
means of vector analysis. In total, 94 eyes of 85 patients were included --
25 of 94 (26.5 %) eyes showed progression of the central K greater than
or equal to 1.50 D; progression took 3.5 years on average. Median time
to progression by Kaplan-Meier analysis was 12 years. Significant
predictors for KC progression were as follows: highest point on the
anterior elevation from the anterior best-fit sphere (BFS), greater than or
equal to 0.04 mm; irregularity index at 3 mm, greater than or equal to 6.5
D; irregularity index at 5 mm, greater than or equal to 6.0 D; thinnest
pachymetry, less than 350 μm at baseline examination; yearly change
rate of anterior BFS, greater than or equal to 0.1 D/year; central K,
greater than or equal to 0.1 D/year; simulated K in maximum, greater than
or equal to 0.15 D/year; simulated K in minimum, greater than or equal to
0.2 D/year; and anterior chamber depth, greater than or equal to 0.0
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mm/year. The dominant with-the-rule pattern of astigmatism at the
baseline examination was changed to an oblique pattern of astigmatism
at the last examination. The authors concluded that mild KC tended to be
progressive in approximately 25 % of patients, and progression lasted 3.5
years on average. They stated that longitudinal changes in the corneal
topography quantitative indices can be used as predictors of KC
progression.
Follow-Up Evaluation of Keratoconus
An UpToDate review on “Keratoconus” (Wayman, 2015) states that
“Corneal topography -- The introduction of corneal topography has helped
in the identification of subtle presentations, which can lead to an earlier
diagnosis. Major topographic patterns found in keratoconus include
asymmetric bowtie, with or without inferior steepening, and skewed radial
axes. However, once the diagnosis is made, serially corneal topography
is of little value in following patients”.
Microphthalmia
Hu and colleagues (2015) determined the typical corneal changes in pure
microphthalmia using a corneal topography system and identified
characteristics that may assist in early diagnosis. Patients with pure
microphthalmia and healthy control subjects underwent corneal
topography analysis to determine degree of corneal astigmatism (mean
A), simulation of corneal astigmatism (sim A), mean keratometry (mean
K), simulated keratometry (sim K), irregularities in the 3 - and 5-mm zone,
and mean thickness of 9 distinct corneal regions. Patients with pure
microphthalmia (n = 12) had significantly higher mean K, sim K, mean A,
sim A, 3.0 mm irregularity and 5.0 mm irregularity, and exhibited
significantly more false keratoconus than controls (n = 12). There was a
significant between-group difference in the morphology of the anterior
corneal surface and the central curvature of the cornea. The authors
concluded that changes in corneal morphology observed in this study
could be useful in borderline situations to confirm the diagnosis of pure
microphthalmia. These preliminary findings need to be validated by well-
designed studies.
Other Experimental Indications
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In a retrospective, clinic-based, case-control study, de Paiva et al (2003)
determined the correlation between the regularity indices of the Tomey
TMS-2N computerized videokeratoscopy (CVK) instrument (Tomey,
Waltham, MA) with conventional measures of dry eye symptoms and
disease. A total of 16 eyes of 16 asymptomatic normal subjects and 74
eyes of 74 patients with reports of ocular irritation were included in this
study. Corneal surface regularity and potential visual acuity indices
(PVAI) of the Tomey TMS-2N CVK instrument were evaluated in patients
with ocular irritation symptoms and in normal subjects. The surface
regularity index (SRI), surface asymmetry index (SAI), PVAI, and irregular
astigmatism index (IAI) of the Tomey TMS-2N were compared between
normal and dry-eye patients. Severity of dry-eye symptoms was
assessed with a validated questionnaire. Schirmer 1 test (without
anesthesia), biomicroscopic meibomian gland evaluation with a
composite severity score (MGD score), fluorescein tear break-up time
(TBUT), and corneal fluorescein staining were performed. The
correlations between CVK indices of the Tomey TMS-2N and the
symptom severity score, Schirmer 1 test, MGD score, TBUT, and corneal
fluorescein staining score were studied. Dry-eye patients had greater
mean symptom severity scores, lower Schirmer 1 test scores, greater
MGD scores, more rapid TBUT, and greater total corneal fluorescein
staining scores (p < 0.001 for all parameters). The SRI, SAI, and IAI
were all significantly greater in dry-eye patients than normal subjects.
These were 0.46 +/- 0.36 (normal) versus 1.09 +/- 0.76 (dry) for the SRI
(p= 0.0017), 0.30 +/- 0.15 (normal) versus 0.90 +/- 1.09 (dry) for the SAI
(p = 0.0321), and 0.42 +/- 0.28 (normal) versus 0.56 +/- 0.24 (dry) for the
IAI (p = 0.0321). The PVAI was significantly lower in the dry-eye patients
(0.89 +/- 0.13) than normal eyes (0.68 +/- 0.23; p = 0.0008). The SRI,
SAI, and IAI were positively correlated with total and central corneal
fluorescein staining scores (p < 0.00001 for all indices). An SRI greater
than or equal to 0.80), SAI (greater than or equal to 0.50), and IAI
(greater than or equal to 0.50) had sensitivities in predicting total corneal
fluorescein staining (score greater than or equal to 3) of 89 %, 69 %, and
82 %, respectively. The specificity of these indices was 80 %, 78 %, and
82 %, respectively. In all 90 eyes, the mean SRI was greater in subjects
older than 50 years (p = 0.012) compared with younger patients, whereas
no age effect was noted in the dry-eye patients. The SRI and PVAI
showed better correlation with symptoms of blurred vision than the best-
corrected visual acuity (BCVA). The authors concluded that patients with
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ocular irritation had an irregular corneal surface that may contribute to
their irritation and visual symptoms. Because of their high sensitivity and
specificity, the regularity indices of the Tomey TMS-2N have the potential
to be used as objective diagnostic indices for dry eye, as well as a means
to evaluate the severity of this disease.
The American Academy of Ophthalmology Cornea/External Disease
Panel’s Preferred Practice Pattern on “Dry Eye Syndrome” (AAO, 2013)
had no recommendation for computerized corneal topography.
The AAO’s guideline on “Herpes simplex virus keratitis” (White and
Chodosh, 2014) does not include a recommendation for corneal
topography.
Furthermore, UpToDate reviews on “Retinal detachment” (Arroyo, 2018)
and “Diagnosis and classification of Sjogren's syndrome” (Baer, 2018) do
not mention corneal topography as a management tool.
CPT Codes / HCPCS Codes / ICD-10 Codes
Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by " +":
Code Code Description
CPT codes covered if selection criteria are met:
92025 Computerized corneal topography, unilateral or bilateral,
with interpretation and report
Other CPT codes related to the CPB:
65710 -
65775
Keratoplasty and other corneal procedures
76514 Ophthalmic ultrasound, diagnostic; corneal pachymetry,
unilateral or bilateral (determination of corneal thickness)
92071 Fitting of contact lens for treatment of ocular surface
disease
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Code Code Description
92310 -
92326
Contact lens services
HCPCS codes covered if selection criteria are met:
Other HCPCS codes related to the CPB:
S0592 Comprehensive contact lens evaluation
S0810 Photorefractive keratectomy (PRK)
S0812 Phototherapeutic keratectomy (PTK)
ICD-10 codes covered if selection criteria are met:
H11.001 -
H11.069
Pterygium of eye
H11.811 -
H11.819
Pseudopterygium of conjunctiva
H16.001 -
H16.079
Corneal Ulcer
H17.9 Unspecified corneal scar and opacity
H18.10 -
H18.13
Bullous keratopathy
H18.461 -
H18.469
Peripheral corneal degeneration [Terrien's marginal
degeneration]
H18.50 -
H18.59
Hereditary corneal dystrophies
H18.601 -
H18.629
Keratoconus
H52.211 -
H52.219
Irregular astigmatism
Q13.4 Other congenital corneal malformations [difficulty fitting
contact lens]
T85.390+ -
T85.398+
Other mechanical complication of other ocular prosthetic
devices, implants and grafts
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Code Code Description
Z94.7 Corneal transplant status
ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):
B60.10 -
B60.13
Acanthamebiasis
D31.10 -
D31.12
Benign neoplasm of cornea [limbal dermoids]
D89.810 -
D89.813
Graft-versus-host disease
H16.141 -
H16.149
Punctate keratitis
H16.221 –
H16.229
Keratoconjunctivitis sicca, not specified as Sjögren's
H16.301 -
H16.399
Interstitial and deep keratitis
H16.8 Other keratitis
H18.451 -
H18.459
Nodular corneal degeneration (e.g., Salzmann's nodular
dystrophy)
H25.011 -
H26.9
Cataract
H27.111 -
H27.139
Subluxation of lens
H35.411 –
H35.419
Lattice degeneration of retina
H40.10 -
H40.159
Open-angle glaucoma
H52.00 –
H52.209,
H52.221
H52.7
Disorders of refraction and accommodation
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Code Code Description
H53.2 Diplopia
Q11.2 Microphthalmus
Q12.0 Congenital cataract
Q87.40 -
Q87.43
Marfan's syndrome
:
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454.
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10. American Academy of Ophthalmology (AAO), Anterior Segment
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Accessed July 9, 2003.
15. Sade de Paiva C, Lindsey JL, Pflugfelder SC. Assessing the severity
of keratitis sicca with videokeratoscopic indices. Ophthalmology.
2003;110(6):1102-1109.
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17. Wolffsohn JS, Peterson RC. Anterior ophthalmic imaging. Clin Exp
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Panel. Primary open-angle glaucoma. Preferred Practice Pattern.
San Francisco, CA: AAO; October 2010.
22. Visser N, Berendschot TT, Verbakel F, et al. Comparability and
repeatability of corneal astigmatism measurements using
different measurement technologies. J Cataract Refract Surg.
2012;38(10):1764-1770.
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23. Choi JA, Kim MS. Progression of keratoconus by longitudinal
assessment with corneal topography. Invest Ophthalmol Vis Sci.
2012;53(2):927-935.
24. Wayman LL. Keratoconus. UpToDate [online serial]. Waltham,
MA: UpToDate; reviewed Novembber 2015.
25. Hu PH, Gao GP, Yu Y, et al. Analysis of corneal topography in
patients with pure microphthalmia in Eastern China. J Int Med
Res. 2015;43(6):834-840.
26. Cavas-Martinez F, De la Cruz Sanchez E, Nieto Martinez J, et al.
Corneal topography in keratoconus: State of the art. Eye Vis
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27. Tummanapalli SS, Potluri H, Vaddavalli PK, Sangwan VS. Efficacy
of axial and tangential corneal topography maps in detecting
subclinical keratoconus. J Cataract Refract Surg.
2015;41(10):2205-2214.
28. Gokul A, Vellara HR, Patel DV. Advanced anterior segment
imaging in keratoconus: A review. Clin Exp Ophthalmol.
2018;46(2):122-132.
29. de Paiva CS, Lindsey JL, Pflugfelder SC. Assessing the severity of
keratitis sicca with videokeratoscopic indices. Ophthalmology.
2003;110(6):1102-1109.
30. American Academy of Ophthalmology Cornea/External Disease
Panel. Preferred Practice Pattern®Guidelines. Dry Eye Syndrome.
San Francisco, CA: American Academy of Ophthalmology; 2013.
Available at: https://www.aao.org/preferred-practice-pattern/dry
eye-syndrome-ppp--2013. Accessed October 8, 2018.
31. White ML, Chodosh J. Herpes simplex virus keratitis: A treatment
guideline – 2014. June 2014. Available at:
https://www.aao.org/clinical-statement/herpes-simplex-virus
keratitis-treatment-guideline. Accessed October 8, 2018.
32. Arroyo JG. Retinal detachment. UpToDate Inc., Waltham, MA. Last
reviewed October 2018.
33. Baer AN. Diagnosis and classification of Sjogren's syndrome.
UpToDate Inc., Waltham, MA. Last reviewed October 2018.
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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and
constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or
program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any
results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna
or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be
updated and therefore is subject to change.
Copyright © 2001-2020 Aetna Inc.
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AETNA BETTER HEALTH® OF PENNSYLVANIA
Amendment to Aetna Clinical Policy Bulletin Number: 0130
Computerized Corneal Topography
There are no amendments for Medicaid.
www.aetnabetterhealth.com/pennsylvania annual 04/01/2020
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