How much does Crosslinking for Keratoconus cost?
There is limited evidence on the costs of corneal crosslinking, but it may be as high as $2,500 to $4,000 per eye in the United States. a cost-effectiveness study estimated the costs of the total treatment for one person as £928 in the UK National Health Service.
Is crosslinkig for keratoconus covered by health insurance?
Since FDA approval of corneal collagen crosslinking (CXL) for keratoconus in April 2016, many insurance companies have started covering this procedure for progressive keratoconus and keratectasia.
What is the CPT code for corneal collagen crosslinking?
Category III CPT 0402T: Collagen crosslinking of cornea, including removal of the corneal epithelium and intraoperative pachymetry when performed.
CPT Category III codes represent temporary codes for new and emerging technologies. They have been created to allow for data collection and utilization tracking for new procedures or services. With this Category III code the individual payers will decide whether to cover the procedure.
Which corneal crosslinking method is covered?
FDA has approved corneal collagen crosslinking (CXL) for progressive keratoconus in April 2016. this approval only covers the crosslinking products developed by Avedro, Inc. this FDA-approved method involves corneal epithelial debridment, hence it is known as epithelium-off or epi-off crosslinking.
At this time, epi-on crosslinking method is not approved by FDA and thus it is not covered.
Below is an updated list of insurance companies in United States that cover corneal collagen crosslinking (CXL) for progressive keratoconus:
| Payer Name | Payer Region | |
|---|---|---|
| Aetna | National | |
| AmeriHealth | DE, NJ, PA | |
| Anthem | National | |
| Arkansas Blue Cross Blue Shield | AR | |
| BCBS Health Advantage | AR | |
| Blue Cross Blue Shield FEP | National | |
| Blue Cross Blue Shield of Alabama | AL | |
| Blue Cross Blue Shield of Arizona | AZ | |
| Blue Cross Blue Shield of Florida | FL | |
| Blue Cross Blue Shield of Georgia | GA | |
| Blue Cross Blue Shield of Illinois | IL | |
| Blue Cross Blue Shield of Kansas | KS | |
| Blue Cross Blue Shield of Kansas City | Kansas City, Northwestern MO, Johnson & Wyandotte Counties | |
| Blue Cross Blue Shield of Louisiana | LA | |
| Blue Cross Blue Shield of Massachusetts | MA | |
| Blue Cross Blue Shield of Michigan | MI | |
| Blue Cross Blue Shield of Minnesota | MN | |
| Blue Cross Blue Sheild of Mississippi | MS | |
| Blue Cross Blue Shield of Montana | MT | |
| Blue Cross Blue Shield of New Mexico | NM | |
| Blue Cross Blue Shield of North Carolina | NC | |
| Blue Cross Blue Shield of North Dakota | ND | |
| Blue Cross Blue Shield of Oklahoma | OK | |
| Blue Cross Blue Shield of Rhode Island | RI, CT, MA | |
| Blue Cross Blue Shield of South Carolina | SC | |
| Blue Cross Blue Shield of Tennessee | TN | |
| Blue Cross Blue Shield of Texas | TX | |
| Blue Cross and Blue Shield of Vermont | VT | |
| Blue Cross of Idaho | ID | |
| Blue Shield of California | CA | |
| BlueChoice Health Plan of South Carolina | SC | |
| Capital Blue Cross | Central PA | |
| Capital Health Plan | FL | |
| CareFirst Blue Cross Blue Shield | MD, DC, Northern VA | |
| Cigna Health | National | |
| ConnectiCare | CT | |
| Dean Health Plan | WI | |
| Emblem Health | NY | |
| Empire Blue Cross Blue Shield | NY | |
| Fallon Health | MA | |
| Geisinger Health | PA, DE, ME, NJ, WV | |
| Harvard Pilgrim | MA | |
| Hawaii Medical Service Association | HI | |
| Health Alliance Plan of Michigan | MI | |
| Health New England | MA | |
| HealthNet | CA, AZ | |
| HealthPartners Minnesota | MN, ND, SD, WI | |
| Highmark Blue Shield | DE, PA, WV | |
| Horizon Blue Cross of New Jersey | NJ | |
| Humana | National | |
| Independence Blue Cross | PA, NJ, DE, MD | |
| John Hopkins HealthCare | MD | |
| Kaiser Permanente | AZ, CA, CO, DC, GA, HI, MD, NV, TX, VA, WA | |
| Medica Health Plans | MN, WI, ND, SD | |
| Medical Mutual | OH | |
| Moda Health | OR | |
| Nebraska Blue | NE | |
| Premera Blue Cross | WA, OR, AK | |
| Presbyterian Health | NM, AZ, CO, TX | |
| Priority Health of Michigan | MI | |
| Providence Health Plan | OR, WA | |
| Public Employee Health Plan (PEHP) | UT | |
| Quartz - Unity Health | WI | |
| Regence Blue Cross Blue Shield | ID, OR, UT, WA | |
| Rocky Mountain Health Plans | CO, NE | |
| Scott & White Health Plan (SWHP) | TX | |
| Select Health | ID, UT | |
| Tricare | TRICARE Policy Manual: Rare Diseases, Eye And Ocular Adnexa, Available to all Tricare beneficiaries, including dependents. also see this comment. | |
| Tufts Health Plan | MA, RI | |
| United Healthcare | National | |
| Wellmark Blue Cross and Blue Shield | IA, SD | |
| This list is subject to change. It is not intended to be a directive, nor is it a suggestion about the likelihood of coverage or reimbursement. Please confirm with your individual carriers. | ||
Avedro's ARCH Program
The ARCH (Avedro Reimbursement Customer Hub) program is a service to help keratoconus patients with reimbursement questions, prescription assistance and the possibility of financial assistance for eligible patients.
Call the ARCH Hotline 844-528-3311 for questions about coding, billing, claims submissions or payer coverage for corneal cross-linking with Photrexa® Viscous and Photrexa® with the KXL® System.
Visit Avedro's website to learn more about insurance coverage and find cornea specialist who perform corneal crosslinking.
Learn more about corneal collagen crosslinking (CXL)
Please update this list to include Tricare Prime, which covered this procedure for my son in both eyes, with a referral from our primary care doctor to the corneal specialist. It was covered at 100%. He had the first eye done in June of 2017 and the second eye done in August of 2017.
ReplyDeleteThank you. we have updated the list and referenced your Facebook comment too.
DeleteI have tricare standard and I’m stationed with my husband in TX. Every dr that I’ve seen is requiring a deposit. However tricare told me that it’s covered 100%
DeleteI have BCBS Federal. I have been going through pre approval for procedure. They denied the claim even though the doctor documented it's progressive and necessary. What can I do now.
DeleteKristen, was it Crosslinking Epi-Off or Epi-On? My son needs it and the office does Epi On hybrid (poking holes in epithelium) which is not FDA approved and said no coverage for Tricare Prime. We have Prime, was wondering what method of procedure is covered.
DeleteCAn you provide more context on the insurance coverage side of things? I saw BCBS of Illinois on your list, but was not able to find the resource on Avedros website that matched that? Also whats the best way to get this covered? One of the docs i saw said it was unlikely and that Avedro upped the price of the drug by 2x so that the CXL procedure is now in the order of $5000-$7000 per eye.
ReplyDeleteBCBS of Illinois is on Avedro's list too. if your claim was denied, you can call Avedro's ARCH program to ask for help. call 844-528-3311 or email ARCH@avedro.com
DeleteThank you so much for this information. I am expecting to find out how BCBSIL is handling our denied claim any day now, and I will call the ARCH program for any further assistance. This is a great help.
DeleteI m with Highmark bcbs PA. They said they dont cover collagen crosslinking.. Do you have any idea about this. Actually we stay in Michigan and my insurance is with my husbands employer based in PA,
ReplyDeleteMy son is having his second eye’s crosslinking done today in Ann Arbor, MI. (2/13/18)
ReplyDeleteHis first was done in the fall; $2,500 for one eye & Insurance covered.
The price for this second eye now in 2018; $13,000 with insurance, $8,000 without insurance!
We live 45 min from Windsor, ON Canada.
Their price is still $1,200-2,500 per eye in Canada.
Just an FYI.
This seems like a similar situation to the Epi-pen price price discrepancy that occurred last year. This company doing the price increases is Avedro.
How is it still the same cost in Canada???
JG
What about texas, they told me my insurance would not cover it. I have blue cross blueshueld. It's gonna be a total of $5500 for both eyes.
ReplyDeleteWhere did you have your consultation? I had one at focal point & it is $9,000 for both eyes.
ReplyDeleteI was just told by my son's doctor that our insurance had denied the claim, but when I called my insurer, they said they never received the claim. The doctor then advised me they were submitting the claims as a group, through a third party. ???? I had to implore them to submit our claim, individually, and I would work with my insurer, if need be. Now I see my insurer on this list. Wonder what all the drama is about? I'm all about keeping the insurance providers honest, but they need to be commended when they are doing the right thing, too.
ReplyDeleteI live in Minnesota and have MEDICA, they've told me repeatedly it's covered under surgical benefits but the billing dept for the cornea dr. insists it's NOT covered. I don't know what to do and really want to have this done. The dr. uses Avedro, etc
ReplyDeleteI am trying to get coverage for collagen cross linking procedure but the doctors office said insurance does not cover it. BCBS told me just to get codes but the doctors office said there are no codes . the procedure was 12,000.00. does anyone know how I can get the codes so that BCBS will consider the claim Thank you
ReplyDeletewe had Cigna Insurance when my daughter had her cross linking surgery. Doctors office said they had to pay up front for the procedure, which they did. I had previously talked with the insurance company and they said it would be covered after deductible.
ReplyDeleteThe doctors office would not submit it to the insurance. After she had several conversations with them, they finally gave her a copy of the bill and I sent it to the insurance myself. They ended up paying her back 2/3 of the cost.
Does anyoone know if this procedure is covered by Cigna Open Access
ReplyDeleteHas anyone gotten a denial from BCBSIL of Illinois, in Washington? Is there a reason why they are denying the claim? Does anyone have any tips for filing the appeal?
ReplyDeletecheck your denial letter from the insurance, the multiple that we received first stated it was considered "experimental" then after MD office provided more details and resubmitted the claim, the denials stated that crosslinking was not covered as the pt did not previously have refractory surgery. Refractory surgery is not the cause of "keratoconus" and not indicated for a person that has keratoconus so this is error in their policy. persistence is the key. when the doctors office states there is no more that they can do, make sure to get ARCH program involved. I believe we were denied 3-4 times which included a doctor peer to peer review and they finally approved the procedure after the doctors office did one final push through the ARCH program, but they have to belong to the ARCH program to make that happen. I was lucky that the doctors office was so persistent and helpful with the claim. this process takes alot of time. I started in Jan.2018 after initial diagnosis in Oct. 2017,(the delay was recommended. to show progression of the disease but was also waiting to see the specialist with more experience with the crosslinking). virtually gave up on the insurance and was told in April 2018 day of the 2nd crosslinking procedure(because my child was diagnosed with it in both eyes) we got approval. It is now May, I have yet to see any bills from the eye surgeon so I do not know what exactly BCBS of Illinois will pay. Good Luck, this is a difficult battle.
DeleteThank you for this. Your timing is almost exactly the same as ours. Just got the second denial from BCBSIL. Our doctor is not the greatest with working on these appeals. My son is checking with his doctor in MA now to see if they can help him with his second eye. The first eye was done in Seattle. I will email ARCH now and see if they can help with our appeal. I will call the doctor to see if they are going to try another appeal, but I highly doubt they will. I don't see how BCBSIL is saying his KC is not medically necessary, so I'm guessing the DR is not submitting some paperwork to prove his condition. Very frustrating!
DeleteI am wondering if anyone that has received approval for the cross linking knows what BCBSIL is paying for the procedures. we received the approval back in April and my son had the cross linking procedures done end march and beginning of April. the interesting part is that we have yet to see a statement and per the doctor's office they are waiting to see what the insurance will pay. has anyone else had this long of a wait to see what the insurance-that gave approval- is paying for the procedure? we are just waiting for bills and are now working through the process of getting the Gas permeable lenses. I am in healthcare and this has been a ridiculous challenge I can see why so many with keratoconus have to settle for less than optimum care and results. we work and pay for insurance our entire adult life and make sure our children are covered and when you need the care you have to make it a full time job to get the approval and coverage. I would like to see more data on the actual outcome- not just see that certain insurance companies are covering/ the FDA approved epi off cross linking. So when I wrote my first reply on 5/24 I was very hopeful about the insurance and the coverage but the longer we wait the more concerned I get.
DeleteIf you got the approval at least they will pay some. I did see one claim through another BCBS that only paid $2600 of a $5200 claim. Thought that was ironic since the day before my son's appt the procedure was $2600 cash but the price had doubled overnight because of the increase of the drug. Last push to get as much money as possible before the patent runs out, I get that. The real irony for us is if the cash price had stayed $2600 we wouldn't be as indignant for insurance BCBSIL to do their job and pay this claim. By the way, BCBSIL has denied our claim so consider yourself headed in the positive direction. You could try a Bing search for "how much does BCBSIL pay on crosslinking claim" to see if someone has posted their story elsewhere.
DeleteAvedro website says this procedure is covered by BCBS in CT, however I called my insurance and they said it is "MEDICALLY UNNECESSARY". anyone have any info on why that is?
ReplyDeleteWe are in Alabama, but our insurance (we do not have the numbers yet as we just got coverage) is through Anthem Blue Cross of Georgia. From what I can find, their policy is Corneal collagen crosslinking (CXL) is considered investigational and not medically necessary for all indications. Does that mean we would just have to fight with them to get it covered?
ReplyDeleteHave your eye care provider send in all the medical documents, and a letter, stating the medical necessity, before you go in for the procedure. Do this at least 40 days before your procedure so the insurer has time to review and issue the authorization. Our eye care provider farmed their billing, or something out, so they never sent in the preauthorization. Thankfully, it is against the law for the provider to require an upfront payment, so they have to bill our insurer, so long as they are in our network. Since they screwed up our billing, our insurer denied our coverage, but I was able to make them see how it is on them to file the appeal on our behalf if they want their money. It is very frustrating, but our insurer had a procedure for getting this paid, and our eye care provider just decided that since it is denied often, they weren't even going to ask. That is very wrong on the part of the provider. We are fighting against so many sides on this battle.
DeleteYes, our doctor is in the Arch program. They never filed any paperwork on our behalf. Our insurance company has not heard from them, even after my repeated calls. They said they use a third party for billing and that it was the third party that must have messed up all of our billing information. It really doesn't matter now since we will not be paying the bill because they have to do their part. The biggest problem is the time limit on the appeal process but hopefully our eye care provider will get something accomplished before that time limit lapses. I am just very disappointed with the dishonesty of the eye care provider. They were suppose to call me back a couple of days ago and I just keep getting, "oh, I have left a message with the person that handles that and they will call you back," which they never do. It really is like dealing with a used car salesman.
DeleteDoes Medicare cover cross linking and if not, are they expected to approve coverage anytime soon?
ReplyDelete