11.05.01h, Refractive Keratoplasty, Keratoprosthesis, and Corneal Collagen Cross-Linking

By July 27, 2026: (1) Billing team must update claim submission system to recognize CPT 0402T as covered ONLY when supporting diagnosis codes document progressive keratoconus (H18.601, H18.602, H18.603, H18.609) or corneal ectasia post-refractive surgery; all other uses deny as experimental/investigational. (2) Update system to deny CPT 0402T claims if procedure is documented as epithelium-on technique; only epithelium-off is covered. (3) For CPT 65770 (Boston KPro), require prior authorization verification that patient meets ALL criteria: (a) cadaveric transplant failure/low success likelihood, (b) severe opaque/vascularized cornea, (c) best-corrected visual acuity ≤20/400 affected eye AND ≤20/40 contralateral eye, (d) no end-stage glaucoma/retinal detachment, (e) qualifying indication (prior graft failure, Stevens-Johnson, OCP, chemical burn, etc.). (4) Deny all other keratoprosthesis devices (not Boston KPro) as experimental/investigational. (5) Verify all refractive keratoplasty claims (CPT 65772, 65775, 66999) document astigmatism correction from trauma or prior eye surgery only; deny cosmetic/refractive error cases. (6) Continue denying LASIK/PRK/PTK (HCPCS S0800, S0810, S0812) and radial keratotomy (CPT 65771) as not eligible. Providers must obtain documentation supporting medical necessity before claim submission or claims will be denied.