Date Printed: February 9, 2010: 06:19 AM

Private Property of Blue Cross and Blue Shield of Florida.
This medical policy (medical coverage guideline) is Copyright 2010, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2010 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association.

02-65000-16

Original Effective Date: 08/15/03

Reviewed: 09/21/09

Revised: 10/15/09

Subject: Phototherapeutic Keratectomy (PTK)

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

DESCRIPTION:

Phototherapeutic keratectomy involves the use of the excimer laser to treat visual impairment or irritative symptoms relating to diseases of the anterior cornea by sequentially ablating uniformly thin layers of corneal tissue. Phototherapeutic keratectomy may be performed in the office setting using topical anesthesia. Phototherapeutic keratectomy must be distinguished from photorefractive keratectomy, which involves the use of the excimer laser to correct refractive errors of the eye (e.g., myopia, astigmatism, hyperopia, and presbyopia).

Phototherapeutic keratectomy (PTK) functions by removing anterior stromal opacities or eliminating elevated corneal lesions while maintaining a smooth corneal surface. Complications of PTK include refractive errors, most commonly hyperopia, corneal scarring, and glare. The U.S. Food and Drug Administration (FDA) labeling for the excimer laser identifies the following ophthalmologic therapeutic indications:

When PTK is used to remove only the epithelial surface of the cornea, the alternative technology is mechanical superficial keratectomy (e.g., corneal scraping). When PTK is used to remove deeper layers of the cornea (e.g., extending into Bowman’s layer), competing technologies include lamellar keratoplasty. In addition, candidates for PTK should have exhausted medical approaches. For example, recurrent corneal erosions can be treated conservatively with lubricants, patching, bandage contact lenses, or anterior stromal punctures, while keratoconus can be treated with rigid contact lenses to correct the astigmatism. There are inadequate data regarding the effectiveness PTK in treating recurrent corneal erosions and infectious keratitis.

POSITION STATEMENT:

Phototherapeutic keratectomy meets the definition of medical necessity when used as an alternative to a lamellar keratoplasty in the treatment of visual impairment or irritative symptoms related to corneal scars, opacities, or dystrophies extending beyond the epithelial layer.

Phototherapeutic keratectomy is experimental or investigational for all other applications and specifically for the treatment of recurrent corneal erosions and infectious keratitis, as there are no controlled clinical studies that have directly compared PTK with other forms of treatment, including superficial keratectomy (used to treat superficial lesions) or lamellar keratoplasty (used to treat deeper lesions) or anterior stromal puncture (used to treat recurrent corneal erosions). There are inadequate data regarding the effectiveness of PTK in treating recurrent corneal erosions and infectious keratitis.

BILLING/CODING INFORMATION:

CPT Coding:

There is no specific CPT code to report PTK.

HCPCS Coding:

ICD-9 Diagnoses Codes That Support Medical Necessity:

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

DEFINITIONS:

Salzmann’s nodular degeneration: a progressive hypertrophic degeneration of the epithelial layer of the epithelial layer of the cornea, Bowman’s membrane, and the outer portion of the corneal stroma.

Keratoconus: a non-inflammatory, usually bilateral protrusion of the cornea, the apex being displaced downward and nasally.

RELATED GUIDELINES:

Keratoplasty, 02-65000-15

OTHER:

Other names used to report PTK:
Corneal modification
Corneal Remodeling

REFERENCES:

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 09/21/09.

GUIDELINE UPDATE INFORMATION:

Private Property of Blue Cross and Blue Shield of Florida.
This medical policy (medical coverage guideline) is Copyright 2010, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2010 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association.

Date Printed: February 9, 2010: 06:19 AM