mp-126 - Medical Policies - Alabama
Policy Number: MP-126
Latest Review Date: July 2022
Corneal pachymetry may be considered medically necessary, once in a lifetime, when performed for the following diagnoses (See Benefit Application):
- Glaucoma; or
- Glaucomatocyclitic crises; or
- Glaucomatous atrophy (cupping) of optic disc; or
- Recession of chamber angle of eye
Corneal pachymetry may be considered medically necessary when performed not more frequently than every six months for the following diagnoses:
- Bullous keratopathy; or
- Corneal edema; or
- Corneal deformities; or
- Corneal degeneration; or
- Corneal rejection post penetrating keratopathy; or
- Cornea transplant; or
- Fuchs endothelial dystrophy; or
- Keratoconus; or
- Post corneal transplant; or
- Posterior polymorphous dystrophy
Corneal pachymetry is considered not medically necessary when performed for routine screening services (e.g., glaucoma screening, routine vision screening).
Corneal pachymetry is considered not medically necessary when used to evaluate refractory errors and as a contract exclusion. (See Benefit Application)
DESCRIPTION OF PROCEDURE OR SERVICE:
Corneal pachymetry is a non-invasive ultrasonic technique for measuring corneal thickness, and has been used primarily in the evaluation of persons with corneal diseases and in the assessment of persons at risk for glaucoma. Ultrasonic corneal pachymetry is performed by placing an ultrasonic probe on the central cornea, after the cornea has been anesthetized with a topical anesthetic. A technician can operate the pachymeter and it normally takes less than 30 seconds per eye to complete measurements.
Corneal thickness is an important indication of the health and function of the cornea. Measurement of corneal thickness is useful for the diagnosis of certain corneal diseases, in determining the effectiveness of specific ophthalmologic medical and surgical treatments such as corneal transplant, penetrating keratoplasty and refractive surgeries and in the evaluation of contact lens wear.
Central corneal thickness has been found to be of predictive value for the development of glaucoma in patients with ocular hypertension. Several techniques have been developed for the clinical measurement of corneal thickness with ultrasound pachymetry considered the gold standard.
The most recent literature review for this policy was performed July 27, 2022.
Summary of Evidence
There is insufficient evidence in the available published, peer-reviewed medical literature to support the use of corneal pachymetry outside of the established indications. The procedure’s clinical efficacy is proven for the established indications.
Practice Guidelines and Position Statements
American Academy of Ophthalmology
The American Academy of Ophthalmology Preferred Practice Pattern on Evaluation of the Glaucoma Suspect (2020) concludes that appropriate testing to evaluate and monitor patients diagnosed as glaucoma suspect includes (among other techniques) pachymetry.
The American Academy of Ophthalmology Preferred Practice Pattern on Corneal Edema and Opacification (2018) concludes that corneal pachymetry, measured in the morning, is a helpful indicator of the ability of the endothelium to regulate corneal hydration appropriately.
U.S. Preventative Task Force Recommendations
Corneal pachymetry, pachymetry, pachymeter, corneal thickness, intraocular pressure, ultrasound pachymetry, optical pachymetry, refractory surgery, IOP, primary open angle glaucoma, POAG, ocular hypertension, central corneal thickness, CCT, Corneal Waveform (CWF), Pachmate®, PalmScan P2000E
APPROVED BY GOVERNING BODIES:
In general, contracts exclude “services for eye exercises, eye refractions, visual training orthoptics, shaping the cornea with contact lenses, or any surgery on the eye to improve vision including radial keratotomy.”
Diagnosis codes covered for once per lifetime procedure of corneal pachymetry may be considered medically necessary. Additional testing for these diagnosis codes should not be necessary unless a patient transfers to another practice or there are corneal changes. If corneal changes occur, then the appropriate diagnosis code should be filed. Procedures performed beyond the once per lifetime limit should include documentation of change in practice or change in condition.
Coverage is subject to member’s specific benefits. Group specific policy will supersede this policy when applicable.
ITS: Home Policy provisions apply
FEP contracts: FEP does not consider investigational if FDA approved and will be reviewed for medical necessity. Special benefit consideration may apply. Refer to member’s benefit plan.
Ophthalmic ultrasound, echography, diagnostic; corneal pachymetry, unilateral or bilateral (determination of corneal thickness)
- American Academy of Ophthalmology Primary Open-Angle Glaucoma Suspect Preferred Practice Pattern®. Nov 2020. https://www.aao.org/preferred-practice-pattern/primary-open-angle-glaucoma-suspect-ppp.
- The American Academy of Ophthalmology Corneal Edema and Opacification Preferred Practice Pattern® Nov 2018. https://www.aao.org/preferred-practice-pattern/corneal-edema-and-opacification-ppp-2018
- Ayala, M, Strandas R. Accuracy of optical coherence tomography (OCT) in pachymetry for glaucoma patients. BMC Ophthalmology 2015; 15:124
- Bohm M, Shajari M, Remy M, Kohnen T. Corneal densitometry after accelerated corneal collagen cross-linking in progressive keratoconus. Int Ophthalmol. 2019; 39(4):765-775.
- Bohnke M, Chavanne P, Gianotti R, Salathe R. Continuous non-contact corneal pachymetry with a high speed reflectometer, Journal of Refractive Surgery. 1998; 14(2):140-146.
- Brandt JD. Corneal thickness in glaucoma screening, diagnosis and management. Curr Opin Ophthalmol. 2004 Aug; 15(2):85-89.
- Brandt JD, Beiser JA, Kass MA, Gordon MO. Central corneal thickness in the Ocular Hypertension Treatment Study (OHTS). Ophthalmology 2001 Oct; 108(10):1779-1788.
- Cheng AC, Rao SK, Lau S, et al. Central corneal thickness measurements by ultrasound, Orbscan II, and Visante OCT after LASIK for myopia. J Refract Surg, April 2008; 24(4): 361-365.
- Ciolino JB, Khachikian SS and Belin MW. Comparison of corneal thickness measurements by ultrasound and Scheimpflug photography in eyes that have undergone laser in situ keratomileusis. Am J Ophthalmol, January 2008; 145(1): 75-80.
- Doughty MJ, Zaman ML. Human corneal thickness and its impact on intraocular pressure measures. A review and meta-analysis approach. Survey of Ophthalmology 2000 Mar-Apr; 44(5):367-408.
- Gordon, Mae O., et al. The ocular hypertension treatment study: Baseline factors that predict the onset of primary open-angle glaucoma, Arch Ophthalmol 2002; 120: 714-20.
- Herman, DC, et al. Increased corneal thickness in patients with ocular hypertension, Arch Ophthalmol, March 2001; 119(3): 334-6.
- Herndon, Leon W., et al. Central corneal thickness as a risk factor for advanced glaucoma damage, Arch Ophthalmol 2004; 122: 17-21.
- Hitchings R, Tan J. Target pressure. J Glaucoma. 2001 Oct; 10(5 Suppl 1):S68-70.
- IOM (Institute of Medicine). 2011. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press.
- Jonas JB, Stroux A, Velten I, et al. Central corneal thickness correlated with glaucoma damage and rate of progression. Invest Ophthalmol Vis Sci 2005; 46:1269-1274.
- Maloca PM, Studer HP, Ambrósio R Jr, Goldblum D, Rothenbuehler S, Barthelmes D, Zweifel S, Scholl HPN, Balaskas K, Tufail A, Hasler PW. Interdevice variability of central corneal thickness measurement. PLoS One. 2018 Sep 13; 13(9):e0203884.
- Medeiros FA, Sample PA, Weinreb RN. Corneal thickness measurements and frequency doubling technology perimetry abnormalities in ocular hypertensive eyes. Ophthalmology. 2003 Oct; 110(10):1903-8.
- Nemesure B, Wu SY, Hennis A, Leske MC. Corneal thickness and intraocular pressure in the Barbados eye studies. Arch Ophthalmol. 2003 Feb; 121(2):240-244.
- Sadoughi MM, Einollahi B, Einollahi N, Rezaei J, Roshandel D, Feizi S. Measurement of Central Corneal Thickness Using Ultrasound Pachymetry and Orbscan II in Normal Eyes. J Ophthalmic Vis Res. 2015 Jan-Mar; 10(1):4-9.
- Sallet G. Comparison of optical and ultrasound central corneal pachymetry, Bull Soc belge Ophtalmol, 281, 35-38, 2001.
- Ventura AC, Böhnke M, Mojon DS. Central corneal thickness measurements in patients with normal tension glaucoma, primary open angle glaucoma, pseudoexfoliation glaucoma, or ocular hypertension. Br J Ophthalmol. 2001 Jul; 85(7):792-5.
- Verdier DD, Sugar A, Baratz K, Beck R, Dontchev M, Dunn S, Gal RL, Holland EJ, Kollman C, Lass JH, Mannis MJ, Penta J; Cornea Donor Study Investigator Group. Corneal thickness as a predictor of corneal transplant outcome. Cornea. 2013 Jun; 32(6):729-36.
Medical Policy Group, July 2003 (1)
Medical Policy Administration Committee, July 2003
Available for comment, July 14-August 27, 2003
Medical Review Committee, May 2004
Medical Policy Administration Committee, June 2004
Available for comment June 28-August 11, 2004
Medical Policy Group, May 2005 (1)
Medical Policy Group, June 2006 (1)
Medical Policy Administration Committee, July 2006
Available for comment July 18-August 31, 2006
Medical Policy Group, November 2007 (1)
Medical Policy Group, September 2008 (2)
Medical Policy Administration Committee, October 2008
Available for comment September 19-November 3, 2008
Medical Policy Group, March 2010 (1): Effective March 1, 2010: Active policy, but no longer scheduled for regular literature reviews. Updated Key Points, no policy change.
Medical Policy Group, October 2013 (1): Removed ICD-9 Diagnosis codes; Added description of diagnosis removed; no change to policy statement.
Medical Policy Group, January 2015 (6): Ad hoc review based on provider request - Updated References; no change in policy statement; policy remains retired
Medical Policy Group, August 2019 (6): Updates to Description, Key Points and Key Words (Corneal Waveform (CWF), Pachmate®, PalmScan P2000E). No change to policy intent.
Medical Policy Group, March 2021 (9): Updates to Key Points, References. Policy statement updated to alphabetize diagnosis bullets and add the word “or” after each diagnosis, no change to policy intent.
Medical Policy Group, July 2022 (9): Reviewed by consensus. References added. No new published peer-reviewed literature available that would alter the coverage statement in this policy. Updates to Key Points, Description. No change to policy statement.
This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.
This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.
The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.
As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.
The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:
1. The technology must have final approval from the appropriate government regulatory bodies;
2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;
3. The technology must improve the net health outcome;
4. The technology must be as beneficial as any established alternatives;
5. The improvement must be attainable outside the investigational setting.
Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:
1. In accordance with generally accepted standards of medical practice; and
2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and
3. Not primarily for the convenience of the patient, physician or other health care provider; and
4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.