Amniotic Membrane Grafting/Transplantation (AMG/AMT) for Ophthalmologic Conditions - (Effective Date - 2026-12-15) 9.01.20
Summary
Excellus BlueCross BlueShield medical policy 9.01.20 covers human amniotic membrane grafting and transplantation for eye conditions and takes effect December 15, 2026 as a new policy. The membrane must be cleared or registered with the FDA as a tissue product for application on the eye, and its use must be consistent with FDA labeling. Grafts are considered medically necessary for listed ophthalmic indications, including acute ocular surface injury, refractory band keratopathy, bullous keratopathy with an epithelial defect, refractory persistent corneal epithelial defect, severe dry eye (DEWS 3 or 4), and Stevens-Johnson syndrome/erythema multiforme.
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