0681 corneal pachymetry - aetna better health€¦ · 16/11/2017 · corneal pachymetry is a...
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Corneal Pachymetry - Medical Clinical Policy Bulletins | Aetna Page 1 of 13
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
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Corneal Pachymetry - Medical Clinical Policy Bulletins | Aetna Page 3 of 13
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
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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
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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 <
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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)
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Code Code Description
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
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Code Code Description
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:
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Corneal Pachymetry - Medical Clinical Policy Bulletins | Aetna Page 9 of 13
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.
4. American Academy of Ophthalmology Glaucoma
Panel. Primary angle closure. Preferred Practice
Pattern. San Francisco, CA: American Academy of
Ophthalmology; 2005.
5. American Academy of Ophthalmology Glaucoma
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
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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.
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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
laser in situ keratomileusis. Am J Ophthalmol.
2008;145(1):75-80.
27. Cheng AC, Rao SK, Lau S, et al. Central corneal
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and Visante OCT after LASIK for myopia. J Refract Surg.
2008;24(4):361-365.
28. Schiano Lomoriello D, Lombardo M, et al. Repeatability
of intra-ocular pressure and central corneal thickness
measurements provided by a non-contact method of
tonometry and pachymetry. Graefes Arch Clin Exp
Ophthalmol. 2011;249(3):429-434.
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29. Modis L Jr, Szalai E, Nemeth G, Berta A. Reliability of
the corneal thickness measurements with the
Pentacam HR imaging system and ultrasound
pachymetry. Cornea. 2011;30(5):561-566.
30. Garcia-Medina JJ, Garcia-Medina M, Garcia-Maturana C,
et al. Comparative study of central corneal thickness
using Fourier-domain optical coherence tomography
versus ultrasound pachymetry in primary open-angle
glaucoma. Cornea. 2013;32(1):9-13.
31. Wu W, Wang Y, Xu L. Meta-analysis of Pentacam vs.
ultrasound pachymetry in central corneal thickness
measurement in normal, post-LASIK or PRK, and
keratoconic or keratoconus-suspect eyes. Graefes Arch
Clin Exp Ophthalmol. 2014;252(1):91-99.
32. Nassiri N, Sheibani K, Safi S, et al. Central corneal
thickness in highly myopic eyes: Inter-device
agreement of ultrasonic pachymetry, Pentacam and
Orbscan II before and after photorefractive
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
of central corneal thickness: Ultrasound pachymetry
versus slit-lamp optical coherence tomography,
specular microscopy, and Orbscan. Clin Ophthalmol.
2015;9:1065-1070.
35. Sadoughi MM, Einollahi B, Einollahi N, et al.
Measurement of central corneal thickness using
ultrasound pachymetry and Orbscan II in normal eyes.
J Ophthalmic Vis Res. 2015;10(1):4-9.Jacobs DS. Open-
angle glaucoma: Epidemiology, clinical presentation,
and diagnosis. UpToDate [online serial], Waltham, MA:
UpToDate; reviewed May 2016.
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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.
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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