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Date Printed: May 27, 2018: 07:34 PM

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This medical policy (medical coverage guideline) is Copyright 2017, 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 2017 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. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

01-92000-22

Original Effective Date: 06/15/03

Reviewed: 03/22/18

Revised: 04/15/18

Subject: Corneal Pachymetry

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.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

Pachymetry is a non-invasive technique used to measure corneal thickness and assess corneal health. It has been used to monitor the progression of disorders that cause corneal thickening or thinning, and the assessment of patient’s at risk for glaucoma. Ultrasound pachymetry is the method most often used and is performed by placing an ultrasonic probe on the central cornea that has been anesthetized. The procedure is also performed prior to certain refractive procedures to determine if the cornea is strong enough for procedures such as LASIK.

POSITION STATEMENT:

Corneal pachymetry meets the definition of medical necessity for ANY ONE of the following indications:

Note: Testing is limited to one (1) in twelve (12) months.

Use of corneal pachymetry is considered experimental or investigational for the following indications:

There is insufficient data available in peer-reviewed literature regarding all other applications to permit conclusions on efficacy and net health outcomes.

Corneal pachymetry does not meet the definition of medical necessity for all other indications including but not limited to:

BILLING/CODING INFORMATION:

CPT Coding:

76514

Opthalmic ultrasound, diagnostic; corneal pachymetry, unilateral OR bilateral (determination of corneal thickness)

REIMBURSEMENT INFORMATION:

Testing is limited to one (1) in twelve (12) months.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage Products: No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found at the time of the last guideline reviewed date.

DEFINITIONS:

Pachymetry: determination of the thickness of material or objects, such as the cornea.

RELATED GUIDELINES:

None applicable.

OTHER:

None applicable.

REFERENCES:

  1. Agency for Healthcare Research and Quality (AHRQ), Effective Health Care Program Comparative Effectiveness Review Number 59, Screening for Glaucoma: Comparative Effectiveness Executive Summary, April 2012.
  2. American Academy of Ophthalmology. (2002). Preferred Practice Pattern- Primary Open-Angle Glaucoma Suspect, 2010, accessed at one.aao.org.
  3. American Academy of Ophthalmology. Preferred Practice Pattern- Primary Open-Angle Glaucoma, 2010, accessed at one.aao.org.
  4. American Academy of Ophthalmology, Primary Open-Angle Glaucoma Suspect Summary Benchmarks for Preferred Practice Pattern Guidelines (2013), accessed at one.aao.org.
  5. ClinicalTrials.gov, Phase 4 Study of Comparison Among 3 Different No-contact Instruments to Valuate Central Corneal Thickness, sponsored by University of Cantanzaro.
  6. ClinicalTrials.gov, Repeatability and Reproducibility of Pachymetric Mapping With Fourier Domain Optical Coherence Tomography, Ocular Response Analyzer, Confoscan 4 and Ultrasound, sponsored by Far Eastern Memorial Hospital.
  7. Dueker DK, et al, Corneal Thickness Measurement in the Management of Primary Open-angle Glaucoma OTA- A Report by the American Academy of Ophthalmology Ophthalmic Technology Assessment Committee Glaucoma Panel, Ophthalmology, September 2007, accessed at aao.org 04/16/12.
  8. ECRI Institute, Detection of Keratoconus by Pre-LASIK Pachymetry Examination, 04/04.
  9. Khaja WA, Grover S, et al. Comparison of central corneal thickness: ultrasound pachymetry versus slit-lamp optical coherence tomography, specular microscopy, and Orbscan. Clin Ophthalmol. 2015 Jun 12;9:1065-70.
  10. National Institute for Health and Clinical Excellence (NICE), Glaucoma: Diagnosis and Management of Chronic Open Angle Glaucoma and Ocular Hypertension, 2009.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 03/22/18.

GUIDELINE UPDATE INFORMATION:

06/15/03

New Medical Coverage Guideline.

01/01/04

HCPCS updates: 0025T deleted; 76514 added.

05/15/04

Additional codes added to MCG for inclusion in ClaimCheck audit; S0830 deleted.

01/01/06

HCPCS update; reference to codes 99271 thru 99275 deleted (codes retired).

05/15/06

Biennial review; ClaimCheck edit removed; reimbursed separately for glaucoma suspect.

09/15/07

Review, guideline reformatted, Medicare Advantage section updated, references updated.

05/15/09

Biennial review: position statements maintained. Medicare Advantage section and references updated.

10/15/10

Revision; related ICD-10 codes added.

03/15/11

Biennial review: position statements maintained and references updated.

10/01/11

ICD-9 coding update.

06/15/12

Review: position statements, coding & billing, guideline title, description section, and references updated; formatting changes.

05/15/13

Annual review; position statements maintained, program exception and references updated.

04/15/14

Annual review; position statements maintained and references updated.

11/01/15

Revision: ICD-9 Codes deleted.

10/01/16

Revision; formatting changes.

04/15/18

Review; position statements maintained, description and references updated.

Date Printed: May 27, 2018: 07:34 PM