Refractive keratoplasty is a generic term that includes all surgical procedures on the cornea to improve vision by changing the refractive index of the corneal surface. Refractive keratoplasties include the following surgeries:

• Radial Keratotomy (RK) is a surgical correction for myopia (nearsightedness). Using a high-powered microscope, the physician places microincisions (usually eight or fewer) on the surface of the cornea in a pattern much like the spokes of a wheel. The incisions are very precise in terms of depth, length, and arrangement. The microincisions allow the central cornea to flatten, thus reducing the convexity of the cornea, which produces an improvement in vision.
• Photorefractive Keratectomy (PRK) uses a computerized laser to correct myopia (nearsightedness). The excimer laser is well-suited for cornea reshaping, because the removal of just tiny amounts of tissue can produce the results needed to correct nearsightedness. The excimer laser produces a beam of ultraviolet light in pulses that last only a few billionths of a second. Each pulse removes a microscopic amount of tissue by evaporating it, producing very little heat and usually leaving underlying tissue almost untouched. Overall, the surgery takes approximately 10–20 minutes; however, the use of the laser beam lasts only 15–40 seconds.
• Automated Lamellar Keratoplasty (ALK) can correct hyperopia. For the treatment of moderate farsightedness, the cornea is opened across the top to form a type of “cap,” using an automated instrument. When the “cap” is positioned back into its original location on top of the eye, microscopic scar tissue is formed, causing the “cap” to bulge out, thus correcting the overly flattened cornea that is associated with hyperopia. Almost like Velcro, the cornea and “cap” adhere to each other, eliminating the need for sutures. Normally, one eye is treated at a time, with about 3 to 4 weeks allowed between each eye surgery. To ease any discomfort, the eye is anesthetized with special drops, and the patient is given a mild sedative to remain relaxed and aware throughout the procedure.
• Minimally Invasive Radial Keratotomy (mini-RK) is intended in cases of myopia, to alter the cornea’s shape and consequently the refraction by reducing the millimeters of cornea that are incised.
• Hexagonal Keratotomy is a form of refractive corneal surgery used to treat naturally occurring hyperopia (far-sightedness) and presbyopia (loss of accommodation in the eyes in advancing age) following radial keratotomy. A hexagonal pattern of intersecting incisions in the cornea is used in performing this procedure.

All of the above procedures can be used alone or in combination to produce the optimal result for a given patient.

• Keratomileusis involves removing, freezing, and lathing the patient’s cornea, followed by its replacement onto the corneal bed. This surgery has been proposed for myopia and aphakic hyperopia (aphakia is the absence of the lens of the eye).
• Keratophakia involves removing the patient’s cornea followed by placement of a lathed donor cornea beneath the recipient’s cornea, which is then reattached. This surgery has been proposed for aphakic hyperopia.
• Epikeratophakia (lamellar keratoplasty) involves suturing a prelathed donor cornea onto the surface of the recipient’s cornea. This surgery has been proposed as a means of correcting adult and pediatric aphakia, keratoconus (a conical protrusion of the cornea, caused by thinning of the stroma, and resulting in major changes in the refractive power of the eye), and myopia.

Radial keratotomy is considered medically necessary in the treatment of myopia that cannot be corrected with lenses (eyeglasses, contacts).

Epikeratophakia is considered medically necessary in the treatment of aphakia.

All other refractive keratoplasty procedures listed under the Description section of the policy are considered investigational.

Codes for refractive corneal surgery, other than the procedures listed above, have been inserted into CPT and are benefits only for the treatment of severe post-surgical astigmatism or astigmatism resulting from trauma (codes 65772–65775).

BlueCard/National Account Issues

Plans may wish to review their contract language on eyeglasses, contact lenses, myopia, and hyperopia to ensure that coverage for, or exclusion of, refractive keratoplasty procedures is consistent with the intent of the contract.

Plans may wish to consider the following criteria when developing contract language/medical policy for radial keratotomy:

• there is a correction of less than 7.0 diopters;
• there is documentation of less than 0.5 diopters change within the last year;
• there is documentation of some clinical condition that precludes use of eyeglasses or contact lenses;
• there are required occupational reasons for correct vision, e.g., airline pilot, fireman.

Plans may wish to consider preauthorization of radial keratotomy or notification to providers that the above listed information must be kept with the patient’s record for purposes of post-payment review.

Radial keratotomy is performed on one eye per scheduled procedure or may require more than one procedure on one eye depending on the individual case. Plans may wish to develop payment guidelines for the coverage of radial keratotomy in single or multiple stages.

CPT code 65772 (corneal relaxing incision for correction of surgically induced astigmatism) may be performed with a radial keratotomy (CPT code 65771). In this case, 65772 is part of the radial keratotomy and should not be coded separately.

A search of the literature was completed through MEDLINE database for the period of January 1992 through February 7, 1996. The search strategy focused on references containing the following Medical Subject Headings:

– Astigmatism (post-operative complications; incision and resection)
 
– Epikeratophakia
 
– Keratomileusis
 
– Keratophakia
 
– Radial Keratotomy

Research was limited to English-language journals on humans.

See also:

TEC Assessment 1988, pp. 14, 169, 177, 197
 
TEC Assessment 1986, p. 97

Epikeratophakia
Excimer Laser Photorefractive Keratectomy
Hexagonal Keratotomy
Keratectomy, Excimer Laser Photorefractive
Keratomileusis
Keratophakia
Keratoplasty, Refractive
Keratotomy, Radial; Minimally invasive, and Hexagonal
Lamellar Keratoplasty
Refractive Keratoplasty