prior authorization review panel mco policy …...the american academy of ophthalmology’s...

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

Proprietary

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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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





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





H53.2 Diplopia

Q11.2 Microphthalmus

Q12.0 Congenital cataract

Q87.40 -

Q87.43

Marfan's syndrome

:

1. Agency for Healthcare Policy and Research (AHCPR), Cataract

Management Guideline Panel. Cataract in adults: Management of

functional impairment. Clinical Practice Guideline No. 4. AHCPR

Pub. No. 93-0542. Rockville, MD: AHCPR; February 1993.

2. Seitz B, Behrens A, Langenbucher A. Corneal topography. Curr

Opin Ophthalmol. 1997;8(4):8-24.

3. Wilson SE, Klyce SD. Advances in the analysis of corneal

topography. Surv Ophthalmol. 1991;35(4):269-277.

4. Morrow GL, Stein RM. Evaluation of corneal topography: Past,

present and future trends. Can J Ophthalmol. 1992;27(5):213

225.

5. Sanders DR, Gills JP, Martin RG. When keratometric

measurements do not accurately reflect corneal topography. J

Cataract Refract Surg. 1993;19 Suppl:131-135.

6. Oshika T, Klyce SD. Corneal topography in LASIK. Semin

Ophthalmol. 1998;13(2):64-70.

7. Goggin M, Alpins N, Schmid LM. Management of irregular

astigmatism. Curr Opin Ophthalmol. 2000;11(4):260-266.

8. Rao SK, Padmanabhan P. Understanding corneal topography.

Curr Opin Ophthalmol. 2000;11(4):248-259.

9. Wilson SE, Ambrisio R. Computerized corneal topography and its

importance to wavefront technology. Cornea. 2001;20(5):441

454.




10. American Academy of Ophthalmology (AAO), Anterior Segment

Panel. Cataract in the adult eye. Preferred Practice Pattern. San

Francisco, CA: AAO; 2006.

11. American Academy of Ophthalmology (AAO). Corneal

opacification and ectasia. Preferred Practice Pattern. San

Francisco, CA: AAO; September 2000.

12. American Academy of Ophthalmology (AAO), Refractive Errors

Panel. Refractive errors & refractive surgery. Preferred Practice

Pattern. San Francisco, CA: AAO; October 2007.

13. American Academy of Ophthalmology (AAO). Corneal

topography. Ophthalmology. 1999;106(8):1628-1638.

14. Majmudar PA. Keratitis, interstitial. eMedicine Ophthalmology

Topic 101. Omaha, NE: eMedicine.com; updated January 31,

2001. Available at: http://www.emedicine.com/oph/topic101.htm.

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.

16. Sherwin T, Brookes NH. Morphological changes in keratoconus:

Pathology or pathogenesis. Clin Experiment Ophthalmol.

2004;32(2):211-217.

17. Wolffsohn JS, Peterson RC. Anterior ophthalmic imaging. Clin Exp

Optom. 2006;89(4):205-214.

18. Sultan G, Baudouin C, Auzerie O, et al. Cornea in Marfan disease:

Orbscan and in vivo confocal microscopy analysis. Invest

Ophthalmol Vis Sci. 2002;43(6):1757-1764.

19. Rapuano CJ. Management of epithelial ingrowth after laser in situ

keratomileusis on a tertiary care cornea service. Cornea.

2010;29(3):307-313.

20. Caster AI, Friess DW, Schwendeman FJ. Incidence of epithelial

ingrowth in primary and retreatment laser in situ keratomileusis.

J Cataract Refract Surg.2010;36(1):97-101.

21. American Academy of Ophthalmology (AAO) Glaucoma

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.


http://www.emedicine.com/oph/topic101.htm

http://eMedicine.com



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

(Lond). 2016;3:5.

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.


https://www.aao.org/preferred-practice-pattern/dry-eye-syndrome-ppp--2013

http://www.aao.org/clinical-statement/herpes-simplex-virus-keratitis-treatment-guideline


https://www.aao.org/preferred-practice-pattern/dry-eye-syndrome-ppp--2013

http://www.aao.org/clinical-statement/herpes-simplex-virus-keratitis-treatment-guideline


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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