|MP 9.03.14||Implantation of Intrastromal Corneal Ring Segments|
|Original Policy Date
|Last Review Status/Date
Reviewed with literature search/9:2014
|Return to Medical Policy Index|
Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract. Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage. Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.
Intrastromal corneal ring segments consist of microthin soft plastic inserts of variable thickness that are placed in the periphery of the cornea. An incision is made in the cornea, and channels are created in it by rotating a lamellar dissector or by using a femtosecond laser. One or 2 corneal implant segments are introduced to each channel, and various implants with a range of implant thicknesses are available for different degrees of correction. They affect refraction in the eye by physically changing the shape of the cornea (flattening the front of the eye), thereby correcting the irregular corneal shape. If required, the implants can be removed at a later date. Intrastromal corneal ring segments have been investigated as a means of improving vision in diseases such as keratoconus and pellucid marginal degeneration, and for refractive surgery to correct mild myopia.
Keratoconus is a progressive bilateral dystrophy that is characterized by paracentral steepening and stromal thinning that impairs visual acuity. Initial treatment often consists of hard contact lenses. A penetrating keratoplasty (ie, corneal grafting) is the next line of treatment in patients who develop intolerance to contact lenses. While visual acuity is typically improved with keratoplasty, perioperative complications are an associated risk; long-term topical steroid use is required; and endothelial cell loss occurs over time, which is a particular concern in younger patients. As an alternative, a variety of keratorefractive procedures have been attempted, broadly divided into subtractive and additive
techniques. Subtractive techniques include photorefractive keratectomy or laser in situ keratomileusis (LASIK), but in general, results of these techniques have been poor. In deep anterior lamellar keratoplasty, pathologic corneal stromal tissue is selectively removed to the level of the Descemet membrane; followed by transplantation of a donor graft. Implantation of intrastromal corneal ring segments represents an additive technique in which the implants are intended to reinforce the cornea, prevent further deterioration, and potentially obviate the need for a penetrating keratoplasty.
Pellucid marginal degeneration is a noninflammatory progressive degenerative disease, typically characterized by bilateral peripheral thinning (ectasia) of the inferior cornea. Deterioration of visual function results from the irregular astigmatism induced by asymmetric distortion of the cornea, and visual acuity typically cannot be restored by using spherocylindrical lenses. Rigid gas permeable contact lenses may be used to treat pellucid marginal degeneration. Intracorneal ring segment implantation, crescentic lamellar keratoplasty, penetrating keratoplasty, and corneal wedge excision have also been proposed.
In myopia, intrastromal inserts correct myopia by flattening the center of the cornea and represent an alternative to LASIK and other refractive surgeries. The proposed advantages of the intrastromal corneal rings are that their insertion does not affect the central cornea, and thus, their effect is not related to the healing process in the cornea. No corneal tissue is removed, and the implants are reversible.
INTACS® represents an intrastromal corneal ring that has received approval by FDA for 2 indications:
In 1999, INTACS inserts were approved through a premarket approval process for the following labeled indication:
“The KeraVision Intacs are intended for the reduction or elimination of mild myopia (-1.00 to -3.00 diopters spherical equivalent at the spectacle plane) in patients:
- Who are 21 years of age or older;
- With documented stability of refraction as demonstrated by a change of less than or equal to 0.50 diopter for at least 12 months prior to the preoperative examination; and
- Where the astigmatic component is +1.00 diopter or less.”
In 2004, INTACS received an additional approval by FDA through the HDE process for the following indication:
“This device is indicated for the reduction or elimination of myopia and astigmatism in patients with keratoconus, who are no longer able to achieve adequate vision with their contact lenses or spectacles, so that their functional vision may be restored and the need for a corneal transplant procedure may potentially be deferred. The specific set of keratoconic patients proposed to be treated with INTACS prescription inserts are those patients:
- Who have experienced a progressive deterioration in their vision, such that they can no longer achieve adequate functional vision on a daily basis with their contact lenses or spectacles;
- Who are 21 years of age or older;
- Who have clear central corneas;
- Who have a corneal thickness of 450 microns or greater at the proposed incision site; AND
- Who have corneal transplantation as the only remaining option to improve their functional vision.”
Note: HDE does not require the manufacturer to provide data confirming the efficacy of the device but rather data supporting its “probable” benefit. The HDE process is available for devices treating conditions that affect fewer than 4000 Americans per year.
Intrastromal corneal ring devices available outside of the United States include:
Ferrara intrastromal corneal ring segment (ICRS)
Keraring intrastromal corneal ring segments (ICRS)
MyoRing intracorneal continuous ring (ICCR)
FDA product code: LQE
Implantation of intrastromal corneal ring segments may be considered medically necessary for the treatment of keratoconus in patients 21 years of age or older who meet the following criteria:
- The patient has experienced a progressive deterioration in their vision, such that they can no longer achieve adequate functional vision with contact lenses or spectacles; AND
- Corneal transplantation is the only alternative to improve their functional vision; AND
- The patient has a clear central cornea with a corneal thickness of 450 m or greater at the proposed incision site.
Implantation of intrastromal corneal ring segments is considered not medically necessary as a treatment of myopia.
Implantation of intrastromal corneal ring segments is considered investigational for all other conditions.
In July 2005, the following CPT category III code was introduced:
0099T: Implantation of intrastromal corneal ring segments
BlueCard/National Account Issues
State or federal mandates (eg, FEP) may dictate that all devices approved by FDA may not be considered investigational, and thus these devices may be assessed only on the basis of their medical necessity.
Plans may wish to review their contract language to ensure that coverage for, or exclusion of, an intrastromal corneal ring is consistent with the intent of the contract. Some Plan benefits or contracts may include an exclusion for refractive eye surgery that would apply to the use of intrastromal corneal ring segments as a treatment of mild myopia.
This policy was created in 2005 and has since been updated periodically using the MEDLINE database. The most recent literature review was performed through July 28, 2014.
Approval by the U.S. Food and Drug Administration (FDA) for the INTACS® device was based on the results of a multi-institutional study involving 361 subjects with mild myopia. Subsequently, the 2-year results of this study were published in the peer-reviewed literature.(1) These data suggested that the intrastromal rings predictably and effectively reduced or eliminated mild myopia (-1.00 to -3.00 diopter) and that the refractive effect was stable over time. However, mild myopia is effectively treated with either spectacles or contact lenses. Therefore, this application of INTACS is considered not medically necessary. In addition, as noted in the Benefits Applications section, many Plan benefits or contracts contain a specific exclusion for refractive eye surgeries.
The published data regarding INTACS for keratoconus consists primarily of single institution case series. These case series indicate that a substantial proportion of patients with keratoconus treated with this system have improved vision at up to 5-year follow-up. Most studies have reported improvements (in uncorrected or corrected visual acuity) in 75% to 80% of patients in whom changes in 2 to 3 lines of corrected or uncorrected visual acuity were considered success.(2-5) Approximately 10% of patients
required a second procedure because of an unsatisfactory initial result.(3,6)
For example, in 2007 Colin and Malet reported 2-year follow-up from a prospective, single-center European study in 100 eyes with keratoconus (82 consecutive patients) and INTACS implantation.(7) Patients had been referred for a penetrating keratoplasty procedure due to contact lens intolerance for correction of myopia and irregular astigmatism. INTACS inserts were removed from 4 eyes (4%) due to poor visual outcome or extrusion, and 14 eyes were lost to follow-up. Of the 82 remaining eyes (68
patients), both corrected and uncorrected visual acuity remained relatively stable between 1 and 2 years of follow-up.
Several retrospective studies have reported stable vision at up to 5 years after INTACS implantation. Bedi et al evaluated the risk of keratoconus progression in a study of 105 consecutive eyes (85 patients) that had undergone INTACS implantation.(8) At 1-year follow-up, 1 eye had extrusion, and 12 (11.4%) had undergone removal of INTACS because of unsatisfactory results; these eyes were managed by penetrating or deep lamellar keratoplasty. Of the 105 eyes, 80% retained the INTACS implant and
showed no keratoconus progression over 5 years of follow-up. Vega-Estrada et al reported that in a series of 51 eyes, the improvement in vision obtained at 6 months after INTACS implantation was maintained out to 5 years postoperatively, although this study only included cases without significant changes in corneal topography over the 12 months before surgery.(9)
Kymionis et al reported 5-year follow-up on 28 patients (36 eyes) who had initially participated in a clinical trial for safety and efficacy of INTACS implantation in patients with keratoconus.(10) In 5 patients (7 eyes), the INTACS segments were removed due to patient dissatisfaction. Five-year follow-up was reported for 17 eyes (59%). Refractive stability was obtained at the 6-month follow-up (spherical equivalent error at baseline -5.54 to -2.68 at 6 months) and remained stable throughout the 5-year follow-up (-3.02). Tenyear follow-up of 30 patients (36 eyes) with keratoconus that had received the Ferrara ring was reported in 2014.11 Only patients who returned for follow-up were included in the study. It was not reported how many patients had undergone the procedure. Excluding 2 eyes that had Ferrara ring exchange and 2 that
underwent keratoplasty, mean corrected distance visual acuity improved from 20/55 at baseline to 20/35 at 5 years and 20/38 at 10 years. This was a significant change from preoperative to 5 years (p<0.05) with no significant change between 5 years and 10 years (p=0.292), suggesting stabilization of keratoconus. Improvement in corrected distance visual acuity of at least 2 lines was observed in 66.7% of patients. Central corneal thickness decreased from 457 µm at baseline to 421 µm at 5 years and 434 µm at 10 years.
One retrospective study compared outcomes between intrastromal corneal ring segments (Keraring, n=30) and deep anterior lamellar keratoplasty (DALK, n=36) in patients with advanced keratoconus.(12) One eye in the DALK group was converted to penetrating keratoplasty and was not included in the analysis. At 24-month follow-up, compared with preoperatively, the DALK group had significantly greater improvement in uncorrected and corrected distance visual acuity and significantly greater reduction in spherical equivalent, manifest cylinder, and K values. The uncorrected distance visual acuity improved by at least 1 line in all eyes in the DALK group. In the intrastromal corneal ring segment group, uncorrected distance visual acuity improved in 24 (80%) eyes, remained unchanged in 3 (10%) eyes, and decreased in 3 (10%) eyes.
Ongoing randomized controlled trials (RCTs) are evaluating combined treatment with INTACS and corneal collagen cross-linking to slow the progression of keratoconus (see Policy No. 9.03.28 [Corneal Collagen Cross-Linking]).
Astigmatism After Penetrating Keratoplasty
Several case series from Europe and South America have been identified in which intrastromal ring segments have been implanted for the correction of residual astigmatism after penetrating keratoplasty. In one of the studies, 9 patients received intrastromal ring segments (Kerarings) for high astigmatism (>4 diopters) after penetrating keratoplasty.(13) Mean keratometry decreased 4.17 diopters (from 46.28 to 42.11). Of the 9 patients, 1 reported night halos, and 2 had the implant removed due to compulsive eye rubbing and vascularization in the stromal tunnel. The authors noted that in patients with a corneal transplant with a diameter of 7.5 mm or smaller, INTACS intrastromal ring segments should not be used because the segments would be close to the graft-host junction.
Pellucid Marginal Degeneration
In 2009, Pinero et al published a European multicenter retrospective analysis of 21 consecutive eyes in 15 patients with intrastromal corneal ring implantation (3 INTACS, 18 Kerarings) for pellucid marginal degeneration who had reduced best-corrected visual acuity (BCVA) and/or contact lens intolerance or dissatisfaction.(14) At 6 months after surgery, uncorrected visual acuity had not changed; 17% of eyes lost lines of BCVA, and 44% of eyes gained 2 lines or greater of BCVA. Ring explantation was performed in 4 eyes (19%) due to visual deterioration during the follow-up. Mean keratometry decreased 1.76 diopters, from 44.95 diopters to 43.19 diopters at 6-months postoperatively.
A 2010 publication from Europe reported a retrospective analysis of intrastromal ring segment implantation (210° arc length Keraring) in 16 consecutive eyes of 10 patients with pellucid marginal degeneration who had reduced BCVA and dissatisfaction with spectacle and contact lens-corrected vision.(15) At 12 months after implantation, uncorrected visual acuity improved from 1.69 logMAR to 0.83 logMAR. At the 36-month follow-up, patients (n=11) had gained a mean of 2.4 lines uncorrected visual acuity and 3.3 lines of spectacle-corrected visual acuity. There was a statistically significant reduction in manifest spherical refraction from -2.43 diopters to -0.72 diopters. For the 11 patients who completed 36-month follow-up, there was no significant change in outcome measures between 12 and 36 months. No
intraoperative or postoperative complications were noted aside from white deposits around the segments in 1 patient.
Updated literature searches have identified a number of case reports of adverse events following implantation of intrastromal corneal ring segments, including persistent pain, extrusion, traumatic shattering, bacterial keratitis, fungal keratitis, corneal edema, deep corneal vascularization, Descemet membrane’s detachment, and alterations of extracellular matrix components and proteinases. In a multicenter series of 251 intrastromal corneal ring segment implantations, 58 eyes of 47 patients had the
devices explanted.(16) The main cause was found to be extrusion (48%), followed by poor refractive outcome (38%), keratitis (7%), and corneal melting and perforation (7%). The time from implantation to explantation ranged from 0.1 to 82 months.
In another study, 6 of 20 eyes had “significant” postoperative problems with regards to thinning and ring exposure, and a dense corneal infiltrate developed in 1 patient at 7 months.(17) Histopathologic examination of 8 eyes that underwent penetrating keratoplasty after removal of INTACS inserts revealed keratocyte apoptosis.(18) Further study long-term is needed to determine whether INTACS reduce or accelerate corneal thinning and progression of keratoconus.
Ongoing and Unpublished Clinical Trials
An online search of ClinicalTrials.gov in July 2014 identified 2 large RCTs on the treatment of keratoconus with combined use of intrastromal corneal ring segments and collagen cross-linking.
- One phase 2/3 randomized trial (NCT01081561) will compare corneal collagen cross-linking in eyes with INTACS compared with eyes without INTACS. The study has an estimated enrollment of 400 subjects with estimated completion in 2015.
- Another phase 3 trial (NCT01112072) will randomly assign subjects to receive collagen crosslinking immediately after, or 3 months after, INTACS implantation. Estimated enrollment is 160 subjects, with an estimated completion date of December 2014.
Clinical Input Received From Physician Specialty Societies and Academic Medical Centers
While the various physician specialty societies and academic medical centers may collaborate with and make recommendations during this process, through the provision of appropriate reviewers, input received does not represent an endorsement or position statement by the physician specialty societies or academic medical centers, unless otherwise noted.
In response to requests, input was received through 1 physician specialty society and 3 academic medical centers while this policy was under review in 2009. The input considered implantation of intrastromal corneal ring segments to be medically necessary for selected patients with keratoconus when the only other option for improving visual acuity is corneal transplantation. The input agreed that implantation of intrastromal corneal ring segments is not medically necessary as a treatment of myopia.
Summary of Evidence
Intrastromal corneal ring segments consist of microthin soft plastic inserts of variable thickness that are placed in the periphery of the cornea. Intrastromal corneal ring segments have been investigated as a means of improving vision in diseases such as keratoconus and pellucid marginal degeneration, and for refractive surgery to correct mild myopia. Clinical input strongly supports the use of intrastromal corneal ring segments in a select group of patients with advanced keratoconus whose only other option for restoration of visual function is the more invasive penetrating keratoplasty. Although questions remain regarding the impact of this procedure on long-term health outcomes, the risk of adverse events is decreased in comparison with the existing alternative (corneal transplant), and there is a potential (as yet unproven) to delay the need for the more invasive procedure. Therefore, use of intrastromal corneal ring segments may be considered medically necessary in patients who meet the U.S. Food and Drug Administration humanitarian device exemption criteria for use of this device. There is insufficient evidence to evaluate health outcomes in patients with pellucid marginal deterioration. Therefore, intrastromal corneal ring segments in this population are considered investigational.
Practice Guidelines and Position Statements
The United Kingdom’s National Institute for Health and Clinical Excellence issued guidance in 2007 on corneal implants for keratoconus.(19) The guidance, based on 9 case series, 1 nonrandomized controlled trial, and specialist advisors’ opinion concluded that “current evidence on the safety and efficacy of corneal implants for keratoconus appears adequate to support the use of this procedure provided that normal arrangements are in place for consent, audit and clinical governance.”
U.S. Preventive Services Task Force Recommendations
Implantation of intrastromal corneal ring segments is not a preventive service.
Medicare National Coverage
There is no national coverage determination (NCD). In the absence of an NCD, coverage decisions are left to the discretion of local Medicare carriers.
- Schanzlin DJ, Abbott RL, Asbell PA et al. Two-year outcomes of intrastromal corneal ring segments for the correction of myopia. Ophthalmology 2001; 108(9):1688-94.
- Alio JL, Shabayek MH, Belda JI et al. Analysis of results related to good and bad outcomes of Intacs implantation for keratoconus correction. J Cataract Refract Surg 2006; 32(5):756-61.
- Colin J. European clinical evaluation: use of Intacs for the treatment of keratoconus. J Cataract Refract Surg 2006; 32(5):747-55.
- Siganos CS, Kymionis GD, Kartakis N et al. Management of keratoconus with Intacs. Am J Ophthalmol 2003; 135(1):64-70.
- Boxer Wachler BS, Christie JP, Chandra NS et al. Intacs for keratoconus. Ophthalmology 2003; 110(5):1031-40.
- Levinger S, Pokroy R. Keratoconus managed with intacs: one-year results. Arch Ophthalmol 2005; 123(10):1308-14.
- Colin J, Malet FJ. Intacs for the correction of keratoconus: two-year follow-up. J Cataract Refract Surg 2007; 33(1):69-74.
- Bedi R, Touboul D, Pinsard L et al. Refractive and topographic stability of Intacs in eyes with progressive keratoconus: five-year follow-up. J Refract Surg 2012; 28(6):392-6.
- Vega-Estrada A, Alio JL, Brenner LF et al. Outcomes of intrastromal corneal ring segments for treatment of keratoconus: Five-year follow-up analysis. J Cataract Refract Surg 2013; 39(8):1234-40.
- Kymionis GD, Siganos CS, Tsiklis NS et al. Long-term follow-up of Intacs in keratoconus. Am J Ophthalmol 2007; 143(2):236-44.
Torquetti L, Ferrara G, Almeida F, et al. Intrastromal corneal ring segments implantation in patients with keratoconus: 10-year follow-up. J Refract Surg. Jan 1 2014;30(1):22-26. PMID 24763145
Ozerturk Y, Sari ES, Kubaloglu A, et al. Comparison of deep anterior lamellar keratoplasty and intrastromal corneal ring segment implantation in advanced keratoconus. J Cataract Refract Surg. Feb 2012;38(2):324-332. PMID 22322167
Arriola-Villalobos P, Diaz-Valle D, Guell JL, et al. Intrastromal corneal ring segment implantation for high astigmatism after penetrating keratoplasty. J Cataract Refract Surg. Nov 2009;35(11):1878-1884. PMID 19878819
Pinero DP, Alio JL, Morbelli H, et al. Refractive and corneal aberrometric changes after intracorneal ring implantation in corneas with pellucid marginal degeneration. Ophthalmology. Sep 2009;116(9):1656-1664. PMID 19643482
Kubaloglu A, Sari ES, Cinar Y, et al. A single 210-degree arc length intrastromal corneal ring implantation for the management of pellucid marginal corneal degeneration. Am J Ophthalmol. Aug 2010;150(2):185-192 e181. PMID 20570241
Ferrer C, Alio JL, Montanes AU, et al. Causes of intrastromal corneal ring segment explantation: clinicopathologic correlation analysis. J Cataract Refract Surg. Jun 2010;36(6):970-977. PMID 20494769
Kanellopoulos AJ, Pe LH, Perry HD, et al. Modified intracorneal ring segment implantations (INTACS) for the management of moderate to advanced keratoconus: efficacy and complications. Cornea. Jan 2006;25(1):29-33. PMID 16331037
Samimi S, Leger F, Touboul D, et al. Histopathological findings after intracorneal ring segment implantation in keratoconic human corneas. J Cataract Refract Surg. Feb 2007;33(2):247-253. PMID 17276265
National Institute for Health and Clinical Excellence (NICE). Guidance on corneal implants for keratoconus. 2007; http://www.nice.org.uk/nicemedia/pdf/IPG227guidance.pdf. Accessed June, 2014.
|CPT||0099T||Implantation of intrastromal corneal ring segments|
|371.60 – 371.62||Keratoconus code range|
|ICD-10-CM (effective 10/1/15)||H18.601-H18.629||Keratoconus code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|08U80JZ, 08U83JZ, 08U8XJZ, 08U90JZ, 08U93JZ, 08U9XJZ||Surgical, eye, supplement, cornea, synthetic substitute, codes for right and left corneas and open, percutaneous and external approaches|
|04/1/05||Add policy to Other section, Vision subsection||New policy|
|03/7/06||Replace policy||Policy updated with literature review; no change in policy statement|
|12/12/06||Replace policy||Policy updated with literature review; no change in policy statement. Reference numbers 6-11 added|
|01/10/08||Replace Policy||Policy updated with literature review; references 12–14 added; no change in policy statement.|
|09/10/09||Replace policy||Policy updated with literature review through August 2009; reference 15 added. Clinical input reviewed; policy statement revised; may be medically necessary in specified conditions.|
|09/16/10||Replace policy||Policy updated with literature review through July 2010; references added; policy statements unchanged|
|09/01/11||Replace policy||Policy updated with literature review through July 2011; reference 17 added; policy statements unchanged|
|9/13/12||Replace policy||Policy updated with literature review through July 2012; Rationale section revised; references 6 and 8 added; some references removed; policy statements unchanged|
|9/12/13||Replace policy||Policy updated with literature review through August 13, 2013; reference 9 added; policy statements unchanged|
|9/11/14||Replace policy||Policy updated with literature review through July 28, 2014;
reference 11 added; policy statements unchanged