CommercialCoverageMedium impact
Corneal Remodeling (CPB 0023, reviewed 2026-06-23)
Aetna·Ophthalmology·Medical Policy
Effective date
Jun 23, 2026
We identified it
Aug 15, 2026
Summary
Aetna updated its Corneal Remodeling policy (CPB 0023) effective June 23, 2026, clarifying medical necessity criteria for corneal relaxing incisions and wedge resections following cataract or transplant surgery, and reaffirming coverage for phototherapeutic keratectomy (PTK) for specific corneal conditions. Key clarification: these procedures are covered even if the member's plan excludes refractive surgery, provided medical necessity criteria are met.
Action Required
By June 23, 2026: Billing team must review and update prior authorization protocols for corneal remodeling procedures to ensure compliance with the updated medical necessity criteria. Specifically: (1) For corneal relaxing incisions (LRIs) and wedge resections—verify that claims are only approved when BOTH conditions are met: astigmatism ≥3.00 diopters AND documented intolerance to glasses/contact lenses, AND member had cataract surgery within 36 months OR corneal transplant within 60 months. (2) For PTK claims—ensure approved indications are limited to: corneal scars/opacities, epithelial membrane dystrophy, irregular surfaces from Salzmann's nodules or keratoconus nodules, recurrent corneal erosions (after conservative measures failed), or superficial corneal dystrophies. Deny PTK for infectious keratitis and other unlisted indications. (3) Update system notes to clarify that LRI/wedge resection coverage applies EVEN FOR PLANS WITH REFRACTIVE SURGERY EXCLUSIONS when medical necessity criteria are met. Provider education staff should communicate this distinction to prevent unnecessary denials. Failure to apply the correct criteria will result in improper claim denials or approvals.