0681 Corneal Pachymetry - Aetna Better Health€¦ · 16/11/2017 · Corneal pachymetry is a...

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Corneal Pachymetry

Policy History

Last Review: 11/16/2017

Effective: 01/02/2004

Next Review: 07/12/2018

Review History

Definitions

Additional Information

Clinical Policy Bulletin

Notes

Number: 0681

Policy *Please see amendment forPennsylvaniaMedicaidat theend of this CPB.

I. Aetna considers ultrasound corneal pachymetry

medically necessary for the following indications:

A. Bullous keratopathy; or

B. Corneal edema; or

C. Corneal refractive surgery (pre- and post-operative

evaluation)*; or

D. Corneal transplant (penetrating keratoplasty) (pre- and

post-operative evaluation); or

E. Evaluation of complications of corneal refractive

surgery (once); or

F. Evaluation of corneal rejection post penetrating

keratoplasty; or

G. Fuchs' endothelial dystrophy; or

H. Persons with glaucoma or glaucoma suspects (testing

is considered medically necessary once per lifetime); or

I. Posterior polymorphous dystrophy

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Aetna considers repeat ultrasound corneal pachymetry

for corneal diseases and injuries (indications D through

I) not medically necessary if performed more frequently

than once every 6 months.

II. Aetna considers corneal pachymetry to be of no proven

value in the work-up of persons prior to cataract surgery

unless corneal disease is documented.

See CPB 0508 - Cataract Removal

Surgery.

III. Aetna considers corneal pachymetry experimental and

investigational for the following indications (not an all-

inclusive list) because its effectiveness for these

indications has not been established.

▪ As a screening test for glaucoma for persons without

signs or symptoms of glaucoma or elevated intra-

ocular pressure

▪ Diagnosis of Marfan syndrome

▪ Diagnosis or monitoring of Terrien's corneal

marginal degeneration

▪ Evaluation of persons with keratoconus

▪ Monitoring of persons on hydroxychloroquine

(Plaquenil)

*Note: Most Aetna benefit plans exclude coverage of refractive

surgery. Please check benefit plan descriptions for details.

Corneal pachymetry for evaluation of persons undergoing

corneal refractive surgery is excluded from coverage under

plans with these provisions.

Note: For purposes of this policy, only the ultrasound method

of corneal pachymetry is considered.

Background




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.

The Ocular Hypertension Treatment Study (Kass et al, 2002;

Gordon et al, 2002), a prospective randomized controlled

clinical trial of glaucoma treatment in persons with elevated

intra-ocular pressure (IOP) greater than or equal to 24 mm Hg,

found central corneal thickness a statistically significant

predictor of development of glaucoma. Corneal thickness was

measured only after the study was initiated, and was not used

to guide therapy. For the enrolled patients, the Ocular

Hypertension Treatment Study results identified central

corneal thickness less than 556 microns and a vertical or

horizontal cup to disc ratio greater than 0.4 (vertical or

horizontal) as risk factors for glaucomatous damage.

The Ocular Hypertension Treatment Study (Kass et al, 2002:

Gordon et al, 2002) results suggested that IOP measurements

need to be adjusted for abnormally thick or thin corneas. The

target IOP is lower for a thin cornea and higher for a thick

cornea. Eyes with thick corneas have a true IOP that is lower

than the measured IOP. Conversely, eyes with thin corneas

have a true IOP that is greater than the measured IOP. Thus,

individuals with thicker corneas may be mis-classified as

having ocular hypertension.

The Ocular Hypertension Treatment Study is the first to

establish corneal thickness as a risk factor for glaucoma.

However, the conclusions of OHTS are limited to persons with

ocular hypertension (greater than 24 mm Hg), and do not

establish the value of corneal pachymetry for screening




persons without ocular hypertension. In addition, there are no

prospective clinical outcome studies demonstrating the clinical

utility of corneal pachymetry in selecting patients for therapy,

for guiding therapy and improving clinical outcomes.

Based on the results of this study, the American Academy of

Ophthalmology Preferred Practice Pattern on Evaluation of the

Glaucoma Suspect (2005) recommended measurement of

corneal thickness with electronic pachymetry in evaluating the

glaucoma suspect.

Repeat measurements of corneal thickness for glaucoma are

not necessary unless the patient has corneal diseases or

surgery affecting corneal thickness. Changes in corneal

thickness with age are minimal in adulthood, with estimated

changes of 0.006 to 0.015 mm per decade (Doughty and

Zaman, 2000).

Corneal pachymetry may be useful in assessing candidates for

penetrating keratoplasty (corneal transplant), and assessing

graft failure and the need for regrafting in corneal transplant

recipients by aiding in the early diagnosis and treatment of

graft rejection. Corneal pachymetry may also be useful in

assessing the response to treatment of corneal transplant

rejection. Corneal pachymetry has also been used to assess

progression of disease in patients with certain corneal

dystrophies and degenerative diseases.

Although keratoconus is associated with corneal thinning,

available evidence indicates that ultrasonic corneal

pachymetry is not as accurate as videokeratography in

diagnosing keratoconus. Rabinowitz et al (1998) compared

the accuracy of ultrasonic pachymetry measurements and

videokeratography-derived indices in distinguishing

keratoconus patients from those with normal eyes. The

investigators measured corneal thickness by ultrasonic

pachymetry at the center and inferior margins of the pupil of

142 normal and 99 keratoconus patients. The corneal surface




topography of patients was studied with videokeratography.

The investigators reported that the range of corneal thickness

in normal and keratoconic eyes overlapped considerably. The

investigators reported that videokeratography indices provided

a 97.5 % correct classification rate and pachymetry data, an

86.0 % rate (p < 0.01). The investigators concluded that

keratoconus is more accurately distinguished from the normal

population by videokeratography-derived indices than by

ultrasonic pachymetry measurements. The investigators

posited that this may be due to the large variation in corneal

thickness in the normal population or the inability of ultrasonic

pachymetry to accurately detect the location of corneal

thinning in keratoconus by measuring standard points on the

cornea. The investigators concluded that pachymetry should

not be relied on to exclude or diagnose keratoconus because

the false-negative and false-positive rates are unacceptably

higher than those obtained by videokeratography.

Sultan and colleagues (2002) examined corneal thickness,

curvature, and morphology with the Orbscan Topography

System I in patients with Marfan syndrome (MFS) and studied

MFS with in-vivo confocal microscopy. This prospective,

clinical, comparative case series included 60 eyes of 31

patients with MFS and 32 eyes of 17 control subjects. First,

biomicroscopic examination was conducted to search for

ectopia lentis. Then, mean keratometry and ocular refractive

power were calculated by the autokeratorefractometer. In each

group, the Orbscan System I mean (and mean

simulated) keratometry and pachymetric measurements (at the

central location and at 8 mid-peripheral locations) were

obtained and compared, and correlations were established.

In-vivo confocal microscopy was performed to evaluate tissue

morphology and Z-scan analysis of 14 thin MFS corneas

compared with 14 control corneas. A significant decrease

(ANOVA, p < 0.0001) of mean simulated keratometry

measurement appeared in the MFS group (sim K, 40.8 +/- 1.4

D) compared with the control group (42.9 +/- 1.1 D).

Pachymetry in the MFS group was significantly decreased (p <




0.0001) compared with that in the control group, in the center

(respectively, 502 +/- 41.9 microm and 552 +/- 23.6 microm)

and the 8 mid-peripheral locations. Ectopia lentis was highly

linked with mean keratometry and pachymetry (p < 0.0001).

Confocal microscopy performed on MFS-affected thin corneas

confirmed the corneal thinning and showed an opaque stromal

matrix, and Z-scan profiles were abnormal with increased

stromal back scattering of light. The authors concluded that

MFS is known to be associated with a flattened cornea. This

study demonstrated an association with corneal thinning and

described confocal microscopy findings in MFS. While the

finding of this study that used the Orbscan System (a slit-

scanning light method) is interesting, there is currently a lack

of evidence to support the use of ultrasound pachymetry in the

diagnosis of MFS.

CPT Codes / HCPCS Codes / ICD-10 Codes

Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":

Code Code Description

CPT codes covered if selection criteria are met:

76514 Ophthalmic ultrasound, diagnostic; corneal

pachymetry, unilateral or bilateral

(determination of corneal thickness)

CPT codes not covered for indications listed in the CPB:

66830 -

66984

Removal of cataract

Other CPT codes related to the CPB:

65710 -

65775

Keratoplasty

65820 Goniotomy

92020 Gonioscopy (separate procedure)





92100 -

92130

Serial tonometry and tonography

Other HCPCS codes related to the CPB:

G0117 Glaucoma screening for high risk patients

furnished by an optometrist or ophthalmologist

G0118 Glaucoma screening for high risk patients

furnished under the direct supervision of an

optometrist or ophthalmologist

S0800 Laser in situ keratomileusis (LASIK)

S0810 Photorefractive keratectomy (PRK)

S0812 Phototherapeutic keratectomy (PTK)

ICD-10 codes covered if selection criteria are met:

H18.10 -

H18.239

Corneal edema and bullous keratopathy

H18.51 Endothelial corneal dystrophy [Fuchs' only]

H18.59 Other hereditary corneal dystrophies [posterior

polymorphous corneal dystrophy]

H40.001 -

H40.33x4

H40.50x0

- H42

Glaucoma

H40.40x0

-

H40.43x4

Glaucoma secondary to eye inflammation

H47.231 -

H47.239

Glaucomatous optic atrophy [cupping]

Q15.0 Congenital glaucoma [Buphthalmos]

T86.840 Corneal transplant rejection





Z94.7 Corneal transplant status

ICD-10 codes not covered for indications listed in the CPB [not all-inclusive]:

B50.0 -

B54

Malaria

H18.461 -

H18.469

Peripheral corneal degeneration [Terrien's

corneal marginal degeneration]

H18.601 -

H18.629

Keratoconus

H25.011 -

H26.9

H28

Age-related and other cataract

M05.40 -

M06.9

Rheumatoid arthritis [not covered for monitoring

plaquenil]

M32.0 -

M32.0

Systemic lupus erythematosus (SLE) [not

covered for monitoring plaquenil]

Q12.0 Congenital cataract

Q87.40 -

Q87.43

Marfan's syndrome

T37.2x1+

-

T37.2x4+

Poisoning by antimalarials and drugs acting on

other blood protozoa

Z13.5 Encounter for screening for eye and ear

disorders

The above policy is based on the following references:




1. American Academy of Ophthalmology

Refractive Management/Intervention Panel. Refractive

errors and refractive surgery. Preferred Practice

Pattern. San Francisco, CA: American Academy of

Ophthalmology; 2007.

2. Canadian Ophthalmological Society. Practice

guidelines for refractive surgery. Policy Statements

and Guidelines. Ottawa, ON: Canadian

Ophthalmological Society; June 2000.

3. American Academy of Ophthalmology Glaucoma

Panel. Primary open-angle glaucoma suspect.

Preferred Practice Pattern. San Francisco, CA:

American Academy of Ophthalmology; 2005.


Panel. Primary angle closure. Preferred Practice

Pattern. San Francisco, CA: American Academy of

Ophthalmology; 2005.


Panel. Primary open-angle glaucoma. Preferred

Practice Pattern. San Francisco, CA: American Academy

of Ophthalmology; 2005.

6. Palmberg P. Answers from the ocular hypertension

treatment study. Archiv Ophthalmol. 2002;120 (6):829-

830.

7. Doughty MJ, Zaman ML. Human corneal thickness and

its impact on intraocular pressure measures: A review

and meta-analysis approach. Surv Ophthalmol.

2000;44(5):367-408.

8. Whitacre MM, Stein RA, Hassanein K. The effect of

corneal thickness on applanation tonometry. Am J

Ophthalmol. 1993;115:592-596.

9. Gordon MO, Beiser JA, Brandt JD, et al. The Ocular

Hypertension Treatment Study: Baseline factors that

predict the onset of primary open angle glaucoma.

Arch Ophthalmol. 2002;120(6):714-719.

10. Kass MA, Heuer DK, Higginbotham EJ, et al. The Ocular

Hypertension Treatment Study: A randomized trial

determines that topical ocular hypertensive




medication delays or prevents the onset of primary

open-angle glaucoma. Archiv Ophthalmol. 2002;120

(6):701-713.

11. Singh RP, Goldberg I, Graham SL, et al. Central corneal

thickness, tonometry and ocular dimensions in

glaucoma and ocular hypertension. J Glaucoma.

2001;10(3):206-210.

12. Lee GA, Khaw PT, Ficker LA, Shah P. The corneal

thickness and intraocular pressure story: Where are

we now? Clin Experiment Ophthalmol. 2002;30(5):334-

337.

13. Bechmann M, Thiel MJ, Neubauer AS, et al. Central

corneal thickness measurements with retinal optical

coherence tomography device versus standard

ultrasonic pachymetry. Cornea. 2001;20(1):50-54.

14. Brandt JD, Beiser JA, Kass MA, et al. Central corneal

thickness in the Ocular Hypertension Treatment Study

(OHTS). Ophthalmology. 2001;108(10):1779-1788.

15. Rainer G, Petternel V, Findl O, et al. Comparison of

ultrasound pachymetry and partial coherence

interferometry in the measurement of central corneal

thickness. J Cataract Refract Surg. 2002;28(12):2142-

2145.

16. Reinstein DZ, Silverman RH, Raevsky T, et al. Arc-

scanning very high-frequency digital ultrasound for 3D

pachymetric mapping of the corneal epithelium and

stroma in laser in situ keratomileusis. J Refract Surg.

2000;16(4):414-430.

17. Giraldez Fernandez MJ, Diaz Rey A, Cervino A, Yerbra-

Pimentel E. A comparison of two pachymetric systems:

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223.

18. Phillips LJ, Cakanac CJ, Eger MW, Lilly ME. Central

corneal thickness and measured IOP: A clinical study.

Optometry. 2003;74(4):218-225.

19. Taravella M, Walker M. Corneal edema, postoperative.

eMedicine Ophthalmology Topic 64. Omaha, NE:

eMedicine.com; updated September 19, 2001.


http://aetnet.aetna.com/mpa/cpb/600_699/0681.htmlhttp://eMedicine.com


20. Brandt JD. Corneal thickness in glaucoma screening,

diagnosis, and management. Curr Opin Ophthalmol.

2004;15(2):85-89.

21. Rabinowitz YS, Rasheed K, Yang H, Elashoff J. Accuracy

of ultrasonic pachymetry and videokeratography in

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(2):196-201.

22. Weissman BA, Yeung KK. Keratoconus. eMedicine

Ophthalmology Topic 104. Omaha, NE:

eMedicine.com; updated January 29, 2005.

23. Sultan G, Baudouin C, Auzerie O, et al. Cornea in

Marfan disease: Orbscan and in vivo confocal

microscopy analysis. Invest Ophthalmol Vis Sci.

2002;43(6):1757-1764.

24. Shih CY, Graff Zivin JS, Trokel SL, Tsai JC. Clinical

significance of central corneal thickness in the

management of glaucoma. Arch Ophthalmol.

2004;122:1270-1275.

25. Li EY, Mohamed S, Leung CK, et al. Agreement among

3 methods to measure corneal thickness: Ultrasound

pachymetry, Orbscan II, and Visante anterior segment

optical coherence tomography. Ophthalmology.

2007;114(10):1842-1827.

26. Ciolino JB, Khachikian SS, Belin MW. Comparison of

corneal thickness measurements by ultrasound and

scheimpflug photography in eyes that have undergone

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27. Cheng AC, Rao SK, Lau S, et al. Central corneal

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28. Schiano Lomoriello D, Lombardo M, et al. Repeatability

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30. Garcia-Medina JJ, Garcia-Medina M, Garcia-Maturana C,

et al. Comparative study of central corneal thickness

using Fourier-domain optical coherence tomography

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31. Wu W, Wang Y, Xu L. Meta-analysis of Pentacam vs.

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32. Nassiri N, Sheibani K, Safi S, et al. Central corneal

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keratectomy. J Ophthalmic Vis Res. 2014;9(1):14-21.

33. Bayhan HA, Aslan Bayhan S, Can I. Comparison of

central corneal thickness measurements with three

new optical devices and a standard ultrasonic

pachymeter. Int J Ophthalmol. 2014;7(2):302-308.

34. Khaja WA, Grover S, Kelmenson AT, et al. Comparison

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2015;9:1065-1070.

35. Sadoughi MM, Einollahi B, Einollahi N, et al.

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angle glaucoma: Epidemiology, clinical presentation,

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UpToDate; reviewed May 2016.




Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan

benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial,

general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care

services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors

in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely

responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is

subject to change.

Copyright © 2001-2018 Aetna Inc.



AETNA BETTER HEALTH® OF PENNSYLVANIA

Amendment toAetna Clinical Policy Bulletin Number: 0681 Corneal Pachymetry

There are no amendments for Medicaid.

www.aetnabetterhealth.com/pennsylvania new 11/01/2018

http://www.aetnabetterhealth.com/pennsylvania

Prior Authorization Review Panel MCO Policy SubmissionCorneal PachymetryCPT Codes / HCPCS Codes / ICD-10 CodesReferencesAmendment to Aetna Clinical Policy Bulletin Number: 0681 Corneal Pachymetry

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