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MEDICAL POLICY POLICY TITLE GAS PERMEABLE SCLERAL CONTACT LENS AND THERAPEUTIC SOFT CONTACT LENS POLICY NUMBER MP-6.031 Original Issue Date (Created): 8/23/2002 Most Recent Review Date (Revised): 5/31/2016 Effective Date: 1/1/2017 POLICY RATIONALE DISCLAIMER POLICY HISTORY PRODUCT VARIATIONS DEFINITIONS CODING INFORMATION DESCRIPTION/BACKGROUND BENEFIT VARIATIONS REFERENCES I. POLICY Corneal liquid bandage is a term that refers to both rigid gas permeable scleral contact lenses (RGP-ScCLs) and therapeutic soft contact lenses (TSCLs). Corneal liquid bandages cover the cornea and sometimes the adjacent portion of the white of the eye (sclera). These lenses are used in the treatment of acute or chronic corneal pathology such as persistent epithelial defects (PEDs). Corneal liquid bandage lens are distinct from soft contact or gas permeable lens used to correct refractive errors. Rigid Gas Permeable Scleral Lens Rigid gas permeable scleral lens may be considered medically necessary for patients who have not responded to topical medications or standard spectacle or contact lens fitting, for the following conditions: Corneal ectatic disorders (e.g., keratoconus, keratoglubus, pellucid marginal degeneration, Terrien’s marginal degeneration, Fuchs’ superficial marginal keratitis, post-surgical ectasia); Corneal scarring and/or vascularization; Irregular corneal astigmatism (e.g., after keratoplasty or other corneal surgery); Ocular surface disease (e.g., severe dry eye, persistent epithelial defects, neurotrophic keratopathy, exposure keratopathy, graft vs. host disease, sequelae of Stevens Johnson syndrome, mucus membrane pemphigoid, post-ocular surface tumor excision, post-glaucoma filtering surgery) with pain and/or decreased visual acuity . Therapeutic Soft Contact Lenses (TSCLs) Hydrophilic soft contact lenses may be considered medically necessary to treat surgical or congenital aphakia. Page 1 MEDICAL POLICY POLICY TITLE GAS PERMEABLE SCLERAL CONTACT LENS AND THERAPEUTIC SOFT CONTACT LENS POLICY NUMBER MP-6.031 The use of therapeutic soft contact lenses used as a corneal bandage may be considered medically necessary as durable medical equipment (DME) when applied and removed by the physician for the treatment of the following but not limited to conditions: Acute or chronic corneal pathology; Permanent keratoprosthesis; After removal of congenital cataracts in an infant; Bullous keratopathy; Dry eyes; Corneal ulcers and erosion; Filamentary keratitis; Persistent epithelial defects (PEDs) resulting from penetrating keratoplasty; Keratoconus; or Neurotrophic corneas resulting from herpes simples/zoster keratitis, congenital corneal anesthesia, familial dysautonomia. Seckle’s syndrome, diabetes, acoustic neuroma surgery, trigeminal ganglionectomy, or trigeminal rhizotomy. II. PRODUCT VARIATIONS Top This policy is applicable to all programs and products administered by Capital BlueCross unless otherwise indicated below. BlueJourney HMO* BlueJourney PPO* FEP PPO** * Refer to Centers for Medicare and Medicaid Services National Coverage Determination 80.1, Hydrophilic Contact Lens for Corneal Bandage, and National Coverage Determination 80.4, Hydrophilic Contact Lenses. * For coverage of refractive lenses used to restore vision due to the surgical removal or congenital absence of an organic lens, refer Durable Medical Equipment Regional Carrier (DME MAC A) Region JA Noridian Healthcare Solutions, LLC Local Coverage Determination (LCD) L33793, Refractive Lenses. ** Refer to FEP Medical Policy Manual MP-9.03.25 Gas Permeable Scleral Contact Lens. The FEP Medical Policy manual can be found at: www.fepblue.org III. DESCRIPTION/BACKGROUND Top Gas Permeable Scleral Contact Lens Gas permeable scleral contact lenses, which are also known as ocular surface prostheses, are formed with an elevated chamber over the cornea and a haptic base over the sclera. Scleral Page 2 MEDICAL POLICY POLICY TITLE GAS PERMEABLE SCLERAL CONTACT LENS AND THERAPEUTIC SOFT CONTACT LENS POLICY NUMBER MP-6.031 contact lenses are being evaluated in patients with corneal disease, including keratoconus, Stevens-Johnson syndrome, chronic ocular graft-versus-host disease, and in patients with reduced visual acuity after penetrating keratoplasty or other types of eye surgery. Scleral contact lenses create an elevated chamber over the cornea that can be filled with artificial tears. The base or haptic is fit over the less sensitive sclera. Scleral contact lens has been proposed to provide optical correction, mechanical protection, relief of symptoms, and facilitation of healing for a variety of corneal conditions. Specifically, the scleral contact lens may neutralize corneal surface irregularities and, by covering the corneal surface in a reservoir of oxygenated artificial tears, function as a liquid bandage for corneal surface disease. This may be called prosthetic replacement of the ocular surface ecosystem (PROSE). The development of materials with high gas permeability and technologic innovations in design and manufacturing has stimulated the use of scleral lenses. The Boston Ocular Surface Prosthesis (Boston Foundation for Sight) is a scleral contact lens that is custom fit using computer-aided design and manufacturing (i.e., computerized lathe). Another design is the Jupiter mini-scleral gas permeable contact lens (Medlens Innovations and Essilor Contact Lens). The Jupiter scleral lens is fit using a diagnostic lens series. The Procornea (Eerbeek) scleral lens was developed in Europe. There are 4 variations of the Procornea: spherical, frontsurface toric, back-surface toric, and bitoric. Lenses are cut with sub micron lathing from a blank. Types of Corneal Liquid Bandage Lenses Corneal liquid bandages are utilized in a large variety of ophthalmic disorders and are considered one of various treatment options. The choice of lens depends on the clinical effect best suited to the corneal condition, though typically TSCLs are tried first. Rigid Gas-Permeable Scleral Contact Lenses (RGP-ScCLs) In the United States (US), scleral contact lenses were previously most often made of a rigid plastic. However, in recent years, a gas-permeable polymer plastic (eg, fluorosilicone/acrylate polymer) has been used to make these lenses, which are now referred to as RGP-ScCLs. RGPScCLs are promoted for daily use and, in some instances, extended use in the treatment of PEDs. The BOSTON® Scleral Lens (BSL), which is more specifically termed the BOSTON® Equalens® II, is the only RGP-ScCL that is commercially available in the US that can be postfabricated for the treatment of PEDs. Currently, it is manufactured and distributed by the Boston Foundation for Sight (Needham Heights, MA). The BSL, unlike a traditional rigid gaspermeable contact lens, is a specially designed, fluid-ventilated, gas-permeable scleral contact lens. It is designed to maintain a bubble-free reservoir of oxygenated aqueous fluid over the corneal surface at a neutral hydrostatic pressure. Due to the fact that air bubbles are avoided, the fluid reservoir functions as a corneal liquid bandage that offers unique therapeutic benefits Page 3 MEDICAL POLICY POLICY TITLE GAS PERMEABLE SCLERAL CONTACT LENS AND THERAPEUTIC SOFT CONTACT LENS POLICY NUMBER MP-6.031 for the management of severe ocular surface disease, in addition to its traditional role of masking irregular corneal astigmatism. Therapeutic Soft Contact Lenses (TSCLs) Therapeutic soft hydrophilic contact lenses (TSCLs) are disposable plastic lenses made of polymer material that are hydrophilic to absorb or attract a certain volume of water and which cover the entire cornea. These soft lenses are worn directly against the cornea and are prescribed for the treatment of acute or chronic corneal pathology such as persistent epithelial defects (PEDs). Many types of soft tissue lenses are available for therapeutic use (e.g., Focus® Night & Day® Lens). Cross-references: MP-2.028 Eye Care MP-1.044 Corneal Surgery, Implantation of Intrastromal Corneal Ring Segment and Corneal Topography/Photokeratoscopy. IV. RATIONALE TOP NA Page 4 MEDICAL POLICY POLICY TITLE GAS PERMEABLE SCLERAL CONTACT LENS AND THERAPEUTIC SOFT CONTACT LENS POLICY NUMBER MP-6.031 V. DEFINITIONS Top APHAKIA is a condition in which part or all of the crystalline lens of the eye is absent, due to a congenital defect or because it has been surgically removed, as in the treatment of cataracts. BULLOUS KERATOPATHY refers to blistering of the cornea, accompanied by corneal swelling. CONGENITAL refers to something, which is present at birth. CORNEA is the transparent anterior portion of the sclera (the fibrous outer layer of the eyeball), about one sixth of its surface: the first part of the eye that refracts light. FILAMENTARY KERATITIS is a condition characterized by the formation of epithelial filaments of varying size and length on the corneal surface. KERATITIS refers to inflammation and ulceration of the cornea, which is usually associated with decreased visual acuity. KERATOCONUS is a conical protrusion of the center of the cornea with blurring of vision, but without inflammation. This occurs most often in persons aged 20 to 60, and is often an inherited disease. KERATOPROSTHESIS refers to replacement of the central area of an opacified cornea by plastic. VI. BENEFIT VARIATIONS Top The existence of this medical policy does not mean that this service is a covered benefit under the member's contract. Benefit determinations should be based in all cases on the applicable contract language. Medical policies do not constitute a description of benefits. A member’s individual or group customer benefits govern which services are covered, which are excluded, and which are subject to benefit limits and which require preauthorization. Members and providers should consult the member’s benefit information or contact Capital for benefit information. VII. DISCLAIMER Top Capital’s medical policies are developed to assist in administering a member’s benefits, do not constitute medical advice and are subject to change. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any medical policy related to their coverage or condition with their provider and consult their benefit information to determine if the service is covered. If there is a discrepancy between this medical policy and a member’s benefit information, the benefit information will govern. Capital considers the information contained in this medical policy to be proprietary and it may only be disseminated as permitted by law. Page 5 MEDICAL POLICY POLICY TITLE GAS PERMEABLE SCLERAL CONTACT LENS AND THERAPEUTIC SOFT CONTACT LENS POLICY NUMBER MP-6.031 VIII. CODING INFORMATION Top Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms of member benefit information. In addition, not all covered services are eligible for separate reimbursement. Covered when medically necessary: CPT Codes® 92071 92313 92325 92072 92314 92310 92315 92311 92316 92312 92317 Current Procedural Terminology (CPT) copyrighted by American Medical Association. All Rights Reserved. Rigid Gas Permeable Scleral Lens Coverage: HCPCS Code S0515 V2531 ICD-10CM Diagnosis Code* D89.810 D89.811 D89.812 H04.121 H04.122 H04.123 H16.401 H16.402 H16.403 H16.411 H16.412 H16.413 H16.431 H16.432 Description Scleral lens, liquid bandage device, per lens Contact lens, scleral, gas permeable, per lens (for contact lens modification, see CPT code 92325) Description Acute graft-versus-host disease Chronic graft-versus-host disease Acute on chronic graft-versus-host disease Dry eye syndrome of right lacrimal gland Dry eye syndrome of left lacrimal gland Dry eye syndrome of bilateral lacrimal glands Unspecified corneal neovascularization, right eye Unspecified corneal neovascularization, left eye Unspecified corneal neovascularization, bilateral Ghost vessels (corneal), right eye Ghost vessels (corneal), left eye Ghost vessels (corneal), bilateral Localized vascularization of cornea, right eye Localized vascularization of cornea, left eye Page 6 MEDICAL POLICY POLICY TITLE GAS PERMEABLE SCLERAL CONTACT LENS AND THERAPEUTIC SOFT CONTACT LENS POLICY NUMBER MP-6.031 ICD-10CM Diagnosis Code* H16.433 H16.441 H16.442 H16.443 H17.01 H17.02 H17.03 H17.11 H17.12 H17.13 H17.811 H17.812 H17.813 H17.821 H17.822 H17.823 H17.89 H17.9 H18.11 H18.12 H18.13 H18.40 H18.411 H18.412 H18.413 H18.421 H18.422 H18.423 H18.43 H18.441 H18.442 H18.443 H18.451 H18.452 H18.453 H18.461 Description Localized vascularization of cornea, bilateral Deep vascularization of cornea, right eye Deep vascularization of cornea, left eye Deep vascularization of cornea, bilateral Adherent leukoma, right eye Adherent leukoma, left eye Adherent leukoma, bilateral Central corneal opacity, right eye Central corneal opacity, left eye Central corneal opacity, bilateral Minor opacity of cornea, right eye Minor opacity of cornea, left eye Minor opacity of cornea, bilateral Peripheral opacity of cornea, right eye Peripheral opacity of cornea, left eye Peripheral opacity of cornea, bilateral Other corneal scars and opacities Unspecified corneal scar and opacity Bullous keratopathy, right eye Bullous keratopathy, left eye Bullous keratopathy, bilateral Unspecified corneal degeneration Arcus senilis, right eye Arcus senilis, left eye Arcus senilis, bilateral Band keratopathy, right eye Band keratopathy, left eye Band keratopathy, bilateral Other calcerous corneal degeneration Keratomalacia, right eye Keratomalacia, left eye Keratomalacia, bilateral Nodular corneal degeneration, right eye Nodular corneal degeneration, left eye Nodular corneal degeneration, bilateral Peripheral corneal degeneration, right eye Page 7 MEDICAL POLICY POLICY TITLE GAS PERMEABLE SCLERAL CONTACT LENS AND THERAPEUTIC SOFT CONTACT LENS POLICY NUMBER MP-6.031 ICD-10CM Diagnosis Code* H18.462 H18.463 H18.49 H18.601 H18.602 H18.603 H18.611 H18.612 H18.613 H18.621 H18.622 H18.623 H18.70 H18.711 H18.712 H18.713 H18.721 H18.722 H18.723 H18.731 H18.732 H18.733 H18.791 H18.792 H18.793 H18.831 H18.832 H18.833 H52.211 H52.212 H52.213 H53.041 H53.042 H53.043 H53.9 H57.11 Description Peripheral corneal degeneration, left eye Peripheral corneal degeneration, bilateral Other corneal degeneration Keratoconus, unspecified, right eye Keratoconus, unspecified, left eye Keratoconus, unspecified, bilateral Keratoconus, stable, right eye Keratoconus, stable, left eye Keratoconus, stable, bilateral Keratoconus, unstable, right eye Keratoconus, unstable, left eye Keratoconus, unstable, bilateral Unspecified corneal deformity Corneal ectasia, right eye Corneal ectasia, left eye Corneal ectasia, bilateral Corneal staphyloma, right eye Corneal staphyloma, left eye Corneal staphyloma, bilateral Descemetocele, right eye Descemetocele, left eye Descemetocele, bilateral Other corneal deformities, right eye Other corneal deformities, left eye Other corneal deformities, bilateral Recurrent erosion of cornea, right eye Recurrent erosion of cornea, left eye Recurrent erosion of cornea, bilateral Irregular astigmatism, right eye Irregular astigmatism, left eye Irregular astigmatism, bilateral Amblyopia suspect, right eye Amblyopia suspect, left eye Amblyopia suspect, bilateral Unspecified visual disturbance Ocular pain, right eye Page 8 MEDICAL POLICY POLICY TITLE GAS PERMEABLE SCLERAL CONTACT LENS AND THERAPEUTIC SOFT CONTACT LENS POLICY NUMBER MP-6.031 ICD-10CM Diagnosis Code* H57.12 H57.13 L12.1 L12.30 L12.31 L12.35 L51.1 L51.2 L51.3 M35.01 T85.318A T85.328A T85.398A T86.840 T86.841 Z98.83 Z98.89 Description Ocular pain, left eye Ocular pain, bilateral Cicatricial pemphigoid Acquired epidermolysis bullosa, unspecified Epidermolysis bullosa due to drug Other acquired epidermolysis bullosa Stevens-Johnson syndrome Toxic epidermal necrolysis [Lyell] Stevens-Johnson syndrome-toxic epidermal necrolysis overlap syndrome Sicca syndrome with keratoconjunctivitis Breakdown (mechanical) of other ocular prosthetic devices, implants and grafts, initial encounter Displacement of other ocular prosthetic devices, implants and grafts, initial encounter Other mechanical complication of other ocular prosthetic devices, implants and grafts, initial encounter Corneal transplant rejection Corneal transplant failure Filtering (vitreous) bleb after glaucoma surgery status Other specified postprocedural states *If applicable, please see Medicare LCD or NCD for additional covered diagnoses Therapeutic Soft Contact Lenses (TSCLs) Coverage: HCPCS Code V2520 V2521 V2522 V2523 Description Contact lens, hydrophilic, spherical, per lens Contact lens, hydrophilic, toric, or prism ballast, per lens Contact lens, hydrophilic, bifocal, per lens Contact lens, hydrophilic, extended wear, per lens *If applicable, please see Medicare LCD or NCD for additional covered diagnoses ICD-10CM Diagnosis Codes* A18.52 B00.52 Description Tuberculous keratitis Herpesviral keratitis Page 9 MEDICAL POLICY POLICY TITLE GAS PERMEABLE SCLERAL CONTACT LENS AND THERAPEUTIC SOFT CONTACT LENS POLICY NUMBER MP-6.031 ICD-10CM Diagnosis Codes* B02.33 B60.13 C69.11 C69.12 D31.11 D31.12 D33.3 E08.3211 E08.3212 E08.3213 E08.3291 E08.3292 E08.3293 E08.3311 E08.3312 E08.3313 E08.3391 E08.3392 E08.3393 E08.3411 E08.3412 E08.3413 E08.3491 Description Zoster keratitis Keratoconjunctivitis due to Acanthamoeba Malignant neoplasm of right cornea Malignant neoplasm of left cornea Benign neoplasm of right cornea Benign neoplasm of left cornea Benign neoplasm of cranial nerves Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, right eye Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, left eye Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, bilateral Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, right eye Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, left eye Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, bilateral Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, right eye Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, left eye Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, bilateral Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, right eye Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, left eye Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, bilateral Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, right eye Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, left eye Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, bilateral Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, right eye Page 10 MEDICAL POLICY POLICY TITLE GAS PERMEABLE SCLERAL CONTACT LENS AND THERAPEUTIC SOFT CONTACT LENS POLICY NUMBER MP-6.031 ICD-10CM Diagnosis Codes* E08.3492 E08.3493 E08.3511 E08.3512 E08.3513 E08.3591 E08.3592 E08.3593 E08.36 E08.39 E09.3211 E09.3212 E09.3213 E09.3291 E09.3292 E09.3293 E09.3311 E09.3312 E09.3313 E09.3391 E09.3392 Description Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, left eye Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, bilateral Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, right eye Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, left eye Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, bilateral Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, right eye Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, left eye Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, bilateral Diabetes mellitus due to underlying condition with diabetic cataract Diabetes mellitus due to underlying condition with other diabetic ophthalmic complication Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye Page 11 MEDICAL POLICY POLICY TITLE GAS PERMEABLE SCLERAL CONTACT LENS AND THERAPEUTIC SOFT CONTACT LENS POLICY NUMBER MP-6.031 ICD-10CM Diagnosis Codes* E09.3393 E09.3411 E09.3412 E09.3413 E09.3491 E09.3492 E09.3493 E09.3511 E09.3512 E09.3513 E09.3591 E09.3592 E09.3593 E09.36 E09.39 E10.3211 E10.3212 E10.3213 E10.3291 E10.3292 E10.3293 Description Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral Drug or chemical induced diabetes mellitus with diabetic cataract Drug or chemical induced diabetes mellitus with other diabetic ophthalmic complication Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral Page 12 MEDICAL POLICY POLICY TITLE GAS PERMEABLE SCLERAL CONTACT LENS AND THERAPEUTIC SOFT CONTACT LENS POLICY NUMBER MP-6.031 ICD-10CM Diagnosis Codes* E10.3311 E10.3312 E10.3313 E10.3391 E10.3392 E10.3393 E10.3411 E10.3412 E10.3413 E10.3491 E10.3492 E10.3493 E10.3511 E10.3512 E10.3513 E10.3591 E10.3592 E10.3593 E10.36 E10.39 E11.3211 Description Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral Type 1 diabetes mellitus with diabetic cataract Type 1 diabetes mellitus with other diabetic ophthalmic complication Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye Page 13 MEDICAL POLICY POLICY TITLE GAS PERMEABLE SCLERAL CONTACT LENS AND THERAPEUTIC SOFT CONTACT LENS POLICY NUMBER MP-6.031 ICD-10CM Diagnosis Codes* E11.3212 E11.3213 E11.3291 E11.3292 E11.3293 E11.3311 E11.3312 E11.3313 E11.3391 E11.3392 E11.3393 E11.3411 E11.3412 E11.3413 E11.3491 E11.3492 E11.3493 E11.3511 E11.3512 E11.3513 Description Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral Page 14 MEDICAL POLICY POLICY TITLE GAS PERMEABLE SCLERAL CONTACT LENS AND THERAPEUTIC SOFT CONTACT LENS POLICY NUMBER MP-6.031 ICD-10CM Diagnosis Codes* E11.3591 E11.3592 E11.3593 E11.36 E11.39 E13.3211 E13.3212 E13.3213 E13.3291 E13.3292 E13.3293 E13.3311 E13.3312 E13.3313 E13.3391 E13.3392 E13.3393 E13.3411 E13.3411 E13.3412 E13.3413 Description Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral Type 2 diabetes mellitus with diabetic cataract Type 2 diabetes mellitus with other diabetic ophthalmic complication Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral Page 15 MEDICAL POLICY POLICY TITLE GAS PERMEABLE SCLERAL CONTACT LENS AND THERAPEUTIC SOFT CONTACT LENS POLICY NUMBER MP-6.031 ICD-10CM Diagnosis Codes* E13.3491 E13.3492 E13.3493 E13.3511 E13.3512 E13.3513 E13.3559 E13.3591 E13.3592 E13.3593 E13.36 E13.39 G50.8 G90.1 H04.121 H04.122 H04.123 H16.001 H16.002 H16.003 H16.011 H16.012 H16.013 H16.021 H16.022 H16.023 H16.031 Description Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral Other specified diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eye Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral Other specified diabetes mellitus with diabetic cataract Other specified diabetes mellitus with other diabetic ophthalmic complication Other disorders of trigeminal nerve Familial dysautonomia [Riley-Day] Dry eye syndrome of right lacrimal gland Dry eye syndrome of left lacrimal gland Dry eye syndrome of bilateral lacrimal glands Unspecified corneal ulcer, right eye Unspecified corneal ulcer, left eye Unspecified corneal ulcer, bilateral Central corneal ulcer, right eye Central corneal ulcer, left eye Central corneal ulcer, bilateral Ring corneal ulcer, right eye Ring corneal ulcer, left eye Ring corneal ulcer, bilateral Corneal ulcer with hypopyon, right eye Page 16 MEDICAL POLICY POLICY TITLE GAS PERMEABLE SCLERAL CONTACT LENS AND THERAPEUTIC SOFT CONTACT LENS POLICY NUMBER MP-6.031 ICD-10CM Diagnosis Codes* H16.032 H16.033 H16.041 H16.042 H16.043 H16.051 H16.052 H16.053 H16.061 H16.062 H16.063 H16.071 H16.072 H16.073 H16.121 H16.122 H16.123 H16.231 H16.232 H16.233 H16.251 H16.252 H16.253 H16.8 H17.01 H17.02 H17.03 H17.11 H17.12 H17.13 H17.811 H17.812 H17.813 H17.821 Description Corneal ulcer with hypopyon, left eye Corneal ulcer with hypopyon, bilateral Marginal corneal ulcer, right eye Marginal corneal ulcer, left eye Marginal corneal ulcer, bilateral Mooren's corneal ulcer, right eye Mooren's corneal ulcer, left eye Mooren's corneal ulcer, bilateral Mycotic corneal ulcer, right eye Mycotic corneal ulcer, left eye Mycotic corneal ulcer, bilateral Perforated corneal ulcer, right eye Perforated corneal ulcer, left eye Perforated corneal ulcer, bilateral Filamentary keratitis, right eye Filamentary keratitis, left eye Filamentary keratitis, bilateral Neurotrophic keratoconjunctivitis, right eye Neurotrophic keratoconjunctivitis, left eye Neurotrophic keratoconjunctivitis, bilateral Phlyctenular keratoconjunctivitis, right eye Phlyctenular keratoconjunctivitis, left eye Phlyctenular keratoconjunctivitis, bilateral Other keratitis Adherent leukoma, right eye Adherent leukoma, left eye Adherent leukoma, bilateral Central corneal opacity, right eye Central corneal opacity, left eye Central corneal opacity, bilateral Minor opacity of cornea, right eye Minor opacity of cornea, left eye Minor opacity of cornea, bilateral Peripheral opacity of cornea, right eye Page 17 MEDICAL POLICY POLICY TITLE GAS PERMEABLE SCLERAL CONTACT LENS AND THERAPEUTIC SOFT CONTACT LENS POLICY NUMBER MP-6.031 ICD-10CM Diagnosis Codes* H17.822 H17.823 H17.89 H17.9 H18.11 H18.12 H18.13 H18.53 H18.55 H18.601 H18.602 H18.603 H18.611 H18.612 H18.613 H18.621 H18.622 H18.623 H18.811 H18.812 H18.813 H27.01 H27.02 H27.03 M35.01 Q07.8 Q12.3 Q87.1 S05.01XA S05.01XD S05.01XS S05.02XA S05.02XD Description Peripheral opacity of cornea, left eye Peripheral opacity of cornea, bilateral Other corneal scars and opacities Unspecified corneal scar and opacity Bullous keratopathy, right eye Bullous keratopathy, left eye Bullous keratopathy, bilateral Granular corneal dystrophy Macular corneal dystrophy Keratoconus, unspecified, right eye Keratoconus, unspecified, left eye Keratoconus, unspecified, bilateral Keratoconus, stable, right eye Keratoconus, stable, left eye Keratoconus, stable, bilateral Keratoconus, unstable, right eye Keratoconus, unstable, left eye Keratoconus, unstable, bilateral Anesthesia and hypoesthesia of cornea, right eye Anesthesia and hypoesthesia of cornea, left eye Anesthesia and hypoesthesia of cornea, bilateral Aphakia, right eye Aphakia, left eye Aphakia, bilateral Sicca syndrome with keratoconjunctivitis Other specified congenital malformations of nervous system Congenital aphakia Congenital malformation syndromes predominantly associated with short stature Injury of conjunctiva and corneal abrasion without foreign body, right eye, initial encounter Injury of conjunctiva and corneal abrasion without foreign body, right eye, subsequent encounter Injury of conjunctiva and corneal abrasion without foreign body, right eye, sequela Injury of conjunctiva and corneal abrasion without foreign body, left eye, initial encounter Injury of conjunctiva and corneal abrasion without foreign body, left eye, subsequent Page 18 MEDICAL POLICY POLICY TITLE GAS PERMEABLE SCLERAL CONTACT LENS AND THERAPEUTIC SOFT CONTACT LENS POLICY NUMBER MP-6.031 ICD-10CM Diagnosis Codes* Description encounter S05.02XS S05.21XA S05.21XD S05.21XS S05.22XA S05.22XD S05.22XS S05.31XA S05.31XD S05.31XS S05.32XA S05.32XD S05.32XS Z94.7 Z98.41 Z98.42 Injury of conjunctiva and corneal abrasion without foreign body, left eye, sequela Ocular laceration and rupture with prolapse or loss of intraocular tissue, right eye, initial encounter Ocular laceration and rupture with prolapse or loss of intraocular tissue, right eye, subsequent encounter Ocular laceration and rupture with prolapse or loss of intraocular tissue, right eye, sequela Ocular laceration and rupture with prolapse or loss of intraocular tissue, left eye, initial encounter Ocular laceration and rupture with prolapse or loss of intraocular tissue, left eye, subsequent encounter Ocular laceration and rupture with prolapse or loss of intraocular tissue, left eye, sequela Ocular laceration without prolapse or loss of intraocular tissue, right eye, initial encounter Ocular laceration without prolapse or loss of intraocular tissue, right eye, subsequent encounter Ocular laceration without prolapse or loss of intraocular tissue, right eye, sequela Ocular laceration without prolapse or loss of intraocular tissue, left eye, initial encounter Ocular laceration without prolapse or loss of intraocular tissue, left eye, subsequent encounter Ocular laceration without prolapse or loss of intraocular tissue, left eye, sequela Corneal transplant status Cataract extraction status, right eye Cataract extraction status, left eye *If applicable, please see Medicare LCD or NCD for additional covered diagnoses IX. REFERENCES Top Baran I, Bradley JA, Alipour F et al. PROSE treatment of corneal ectasia. Cont Lens Anterior Eye xPerry Rosenthal Received: July 1, 2011; Received in revised form: April 23, 2012; Accepted: April 27, 2012; Published Online: May 28, 2012. Boston Foundation for Sight. Physician's guide to Prosthetic replacement of the ocular surface ecosystem (PROSE). [Boston Foundation for Sight Web site]. [Website]: http://www.bostonsight.org/index.cfm?pg=367&pgtitle=About-our-Treatment Accessed March 22, 2016. Page 19 MEDICAL POLICY POLICY TITLE GAS PERMEABLE SCLERAL CONTACT LENS AND THERAPEUTIC SOFT CONTACT LENS POLICY NUMBER MP-6.031 Centers for Medicare and Medicaid Services National Coverage Determination (NCD) 80.4, Hydrophilic Contact Lens. CMS [Website]: http://www.cms.gov/medicare-coveragedatabase/search/document-id-search-results.aspx?DocID=80.4&bc=gAAAAAAAAAAA& Accessed March 22, 2016... Centers for Medicare and Medicaid Services National Coverage Determination (NCD) 80.1, Hydrophilic Contact Lens for Corneal Bandage. CMS [Website]: http://www.cms.gov/medicare-coverage-database/search/document-id-searchresults.aspx?DocID=80.1&bc=gAAAAAAAAAAA& Accessed March 22, 2016.. Durable Medical Equipment Regional Carrier (DME MAC A) Region JA Noridian Healthcare Solutions, LLC Local Coverage Determination (LCD) Refractive Lenses LCD L33793. Effective 10/1/15. [Website]: http://www.medicarenhic.com/index.shtml. March 22, 2016. Gumus K, Gire A, Pflugfelder SC. The successful use of Boston ocular surface prosthesis in the treatment of persistent corneal epithelial defect after herpes zoster ophthalmicus.Cornea. 2010 Dec;29(12):1465-8. Mondofacto Online Medical Dictionary. [Website]: http://www.mondofacto.com/about/aboutus.html Accessed March 22, 2016.. Mosby's Medical, Nursing, & Allied Health Dictionary, 6th edition. Pecego M, Barnett M, Mannis MJ et al. Jupiter Scleral Lenses: the UC Davis Eye Center experience. Eye Contact Lens 2012; 38(3):179-82 Schornack MM, Patel SV. Scleral lenses in the management of keratoconus. Eye Contact Lens 2010; 36(1):39-44. Stason WB, Razavi M, Jacobs DS et al. Clinical benefits of the Boston Ocular Surface Prosthesis. Am J Ophthalmol 2010; 149(1):54-61. Taber's Cyclopedic Medical Dictionary 20th edition. X. POLICY HISTORY MP 6.031 TOP CAC 4/27/04 CAC 12/14/04 CAC 9/27/05 CAC 9/26/06 CAC 9/25/07 CAC 7/29/08 CAC 7/28/09 Consensus review CAC 1/26/10 Full review. Policy revised for clarity. Information added regarding the Boston Scleral Lens, considered medically necessary. CAC 4/26/11 Consensus CAC 11/29/11 Adopted BCBSA for Gas Permeable Scleral Contact Lens (remain medically necessary). Changed title to reflect BCBSA adoption. The existing CBC criteria Page 20 MEDICAL POLICY POLICY TITLE GAS PERMEABLE SCLERAL CONTACT LENS AND THERAPEUTIC SOFT CONTACT LENS POLICY NUMBER MP-6.031 for therapeutic soft hydrophilic contact lenses remain unchanged. CAC 1-29-13 Consensus. No change to policy statements. References updated. Added FEP variation to reference MP-9.03.25 Gas Permeable Scleral Contact Lens Codes reviewed 1/8/13 02/27/13- Removed 92499 from policy 05/20/13- Administrative code review complete CAC 1/28/14 Consensus review. No changes to the policy statements. References updated. Codes reviewed. CAC 1/27/15 Consensus. No change to policy statements. References updated. 9/3/15 Administrative change. For the Medicare variation - Added reference to NCD 80.5. Coding reviewed. 10/9/15 Administrative change. Medicare variation 80.5 deleted. This variation does not apply to policy statements. 11/2/15 Administrative change. LCD number changed from L11532 to L33793 due to NHIC update to ICD 10. CAC 5/31/16 Consensus review. No change to policy statements. References updated. Coding reviewed. Changed DME Medicare carrier from NHIC to Noridian. Admin update 1/1/17: Product variation section reformatted. New diagnosis codes added effective 10/1/16 Top Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company®, Capital Advantage Assurance Company® and Keystone Health Plan® Central. Independent licensees of the BlueCross BlueShield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. Page 21
