Does Your Insurance Cover Crosslinking for Keratoconus?



Update June 2017: Corneal Crosslinking Insurance Coverage in the United States


Does your insurance cover crosslinking for keratoconus?

We don't usually post news on our blog, but we have got an interesting news from one of our members from Minnesota which we had to share it with you.

Aetna now considers epithelium-off corneal collagen cross-linking medically necessary for keratoconus and pays for it.

Here is Aetna's policy regarding collagen cross-linking (CPT code 0402T):

"Aetna considers epithelium-off photochemical collagen cross-linkage using riboflavin and ultraviolet A medically necessary for keratoconus and keratectasia. Photochemical collagen cross-linkage is considered experimental and investigational for all other indications because its effectiveness for other indications has not been established. Epithelium-on (transepithelial) collagen cross-linkage is considered experimental and investigational for keratoconus, keratectasia, and all other indications. Performance of photochemical collagen cross-llinkage in combination with other procedures (CXL-plus) (e.g., intrastromal corneal ring segments, PRK or phakic intra-ocular lens implantation) is considered experimental and investigational."

UPDATE November 2: Many thanks to the International Keratoconus Academy Medical Advisory Board member Dr. Ryan McKinnis for this recent Aetna view on CXL!

We are not sure if there is any other insurance company covering crosslinking for keratoconus. Please reach out to your insurance and let us know if they have similar policy and consider crosslinking medically necessary for keratoconus

Another insurance company which I checked (I will not disclose their name) have the following policy:

Corneal collagen cross-linking is considered investigational for all applications. [NAME REMOVED] does not provide coverage for investigational services or procedures.
It is good to know that the code assigned to crosslinking, 0402T, is a category III CPT code. category III CPT codes are defined as "temporary codes for emerging technology, services and procedures".

"Some payors would take a shortcut to making a non-coverage decision for services described by Category III codes, based on the incorrect conclusion that Category III code status was a de facto determination that the service was experimental or investigational." says John S. McInnes, MD. Source: Healio OSN

According to Bennie H. Jeng, MD, et al "Because CXL ultimately should decrease the number of corneal transplants required, insurance companies should take a serious look at the cost-to-benefit ratio in covering the procedure." Source: Ophthalmology

FDA approval

In case you missed it (I doubt it!), FDA has approved corneal collagen cross-linking for keratoconus in April. this approval only covers the cross-linking products developed by Avedro, Inc.

To learn more, check out this article from NKCF: Crosslinking Update: Understanding what FDA Approval Means and read this helpful note from the NKCF's Executive Director, Mary Prudden:

1 comment:

  1. Good news hopefully this is only a start others will do the same

    ReplyDelete