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Clinical Policy Bulletin:
Computerized Corneal Topography
Number: 0130


Policy

  1. 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)*; 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); 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 examination.  Repeat testing to monitor disease progression in keratoconus or Terrien's marginal degeneration may be necessary over time.

  2. Note: Aetna does not cover corneal topography if it is performed pre- or post-operatively in relation to a non-covered procedure (i.e., refractive eye surgery).  Most Aetna benefit plans exclude coverage of refractive surgery.  Please check benefit plan descriptions for details.

  3. 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).

  4. 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
  • Epithelial ingrowth following laser in situ keratomileusis (LASIK)
  • Interstitial keratitis
  • Lens subluxation (e.g., in Marfan syndrome)
  • Limbal dermoids
  • Nodular degeneration of the cornea (e.g., Salzmann's corneal degeneration)
  • Ocular graft-versus-host disease
  • Open-angle glaucoma
  • Superficial punctate keratopathy.


Background

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-angle glaucoma.

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 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.

 
CPT Codes / HCPCS Codes / ICD-9 Codes
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
76514
92071
92310 - 92326
HCPCS codes covered if selection criteria are met:
S0820 Computerized corneal topography, unilateral
Other HCPCS codes related to the CPB:
S0592 Comprehensive contact lens evaluation
S0810 Photorefractive keratectomy (PRK)
S0812 Phototherapeutic keratectomy (PTK)
ICD-9 codes covered if selection criteria are met:
367.22 Irregular astigmatism
370.00 - 370.07 Corneal Ulcer
371.00 Corneal opacity, unspecified
371.01 Minor opacity of cornea [post-traumatic scarring]
371.02 Peripheral opacity of cornea [post-traumatic scarring]
371.03 Central opacity of cornea [post-traumatic scarring]
371.23 Bullous keratopathy
371.48 Peripheral degeneration of cornea [Terrien's marginal degeneration]
371.50 - 371.58 Hereditary corneal dystrophies
371.60 - 371.62 Keratoconus
372.40 - 372.45 Pterygium
372.52 Pseudopterygium
743.41 Anomalies of corneal size and shape
996.51 Mechanical complications due to corneal graft
V42.5 Cornea transplant
ICD-9 codes not covered for indications listed in the CPB (not all-inclusive):
136.21 Specific infection due to acanthameoba
224.4 Benign neoplasm of cornea [limbal dermoids]
279.50 - 279.53 Graft-versus-host disease
365.10 - 365.15 Open-angle glaucoma
366.00 - 366.9 Cataract
370.21 Punctate keratitis [Ocular]
370.50 - 370.59 Interstitial and deep keratitis
370.8 Other forms of keratitis [acanthamoeba keratitis]
371.46 Nodular degeneration of cornea (e.g., Salzmann's nodular dystrophy)
379.32 Subluxation of lens
379.33 Anterior dislocation of lens
379.34 Posterior dislocation of lens
743.30 - 743.34 Congenital cataract
759.82 Marfan's syndrome


The above policy is based on the following references:
  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.
  23. Choi JA, Kim MS. Progression of keratoconus by longitudinal assessment with corneal topography. Invest Ophthalmol Vis Sci. 2012;53(2):927-935.


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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.
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