Clinical Policy Title: Corneal transplants (keratoplasty)

Transcription

1 Clinical Policy Title: Corneal transplants (keratoplasty) Clinical Policy Number: Effective Date: April 1, 2015 Initial Review Date: November 19, 2014 Most Recent Review Date: November 16, 2017 Next Review Date: November 2018 Related policies: Policy contains: Corneal transplant. Penetrating keratoplasty (PK). Lamellar (partial thickness) keratoplasty (LK). Endothelial keratoplasty (EK). Keratoprosthesis. CP# CP# Corneal implants Therapeutic contact lenses ABOUT THIS POLICY: AmeriHealth Caritas Pennsylvania Community HealthChoices has developed clinical policies to assist with making coverage determinations. AmeriHealth Caritas Pennsylvania HealthChoices clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services (CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peer-reviewed professional literature. These clinical policies along with other sources, such as plan benefits and state and federal laws and regulatory requirements, including any state- or plan-specific definition of medically necessary, and the specific facts of the particular situation are considered by AmeriHealth Caritas Pennsylvania HealthChoices when making coverage determinations. In the event of conflict between this clinical policy and plan benefits and/or state or federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control. AmeriHealth Caritas Pennsylvania HealthChoices clinical policies are for informational purposes only and not intended as medical advice or to direct treatment. Physicians and other health care providers are solely responsible for the treatment decisions for their patients. AmeriHealth Caritas Pennsylvania HealthChoices clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, AmeriHealth Caritas Pennsylvania HealthChoices will update its clinical policies as necessary. AmeriHealth Caritas Pennsylvania HealthChoices clinical policies are not guarantees of payment. Coverage policy AmeriHealth Caritas Pennsylvania HealthChoices considers corneal transplants to be clinically proven and, therefore, medically necessary for the treatment of corneal opacification or corneal edema if significant tissue thickness is involved, or a compromised corneal endothelium that is unresponsive to conservative measures. Common indications include, but are not limited to (American Academy of Ophthalmology [AAO], 2013): Bullous keratopathy. Hereditary conditions (e.g., Fuchs endothelial corneal dystrophy [FECD]). Corneal thinning or descemetocele and potential for perforation. Keratoconus. Graft rejection following a previous corneal transplant. Corneal failure due to cataract surgery complications. 0

2 AmeriHealth Caritas Pennsylvania HealthChoices considers the following corneal transplant procedures to be clinically proven and, therefore, medically necessary (AAO, 2017; AAO, 2013): Penetrating keratoplasty (PK) for congenital or acquired causes of corneal opacities when functional vision with eyeglasses or contact lenses can no longer be achieved, or when persistent corneal edema occurs following hydrops. Lamellar keratoplasty (e.g., Deep anterior lamellar keratoplasty [DALK]) for disease processes involving the stroma without significant scarring or hydrops in the presence of healthy endothelium. Endothelial keratoplasty (EK) using Descemet s stripping endothelial keratoplasty (DSEK), Descemet s stripping automated endothelial keratoplasty (DSAEK), or Descemet s membrane endothelial keratoplasty (DMEK) for treatment of endothelial dysfunction in the absence of corneal scarring, for example for (AAO, 2017): - Bullous keratopathy. - Corneal edema. - Posterior corneal dystrophies. - Rupture in Descemet s membrane. - Endothelial corneal dystrophy and other posterior corneal dystrophies. - Mechanical complications due to corneal graft or ocular lens prostheses. - Iridocorneal endothelial syndrome. Boston Keratoprosthesis (Boston KPro, Massachusetts Eye and Ear Infirmary [MEEI], North Attleboro, Massachusetts) for the treatment of severe corneal opacification when all of the following criteria are met (MEEI, 2017; Lee, 2015): - Member is at least 18 years of age (Fung, 2017). - Failed cadaveric corneal graft with poor prognosis for further grafting. - Vision less than 20/200 in the affected eye and compromised vision in the opposite eye. - No end-stage glaucoma or retinal detachment. AmeriHealth Caritas Pennsylvania HealthChoices considers tissue procurement, preservation, storage, and transportation associated with medically necessary corneal transplantation to be medically necessary. Limitations: The following corneal transplant procedures are not medically necessary: DMEK, DSEK, or DSAEK to treat conditions of the corneal stroma or conditions with concurrent endothelial disease and anterior corneal dystrophies (e.g., keratoconus or corneal ulcers caused by infection and traumatic corneal injuries). PK when performed solely to correct astigmatism or other refractive errors. DALK in the presence of unhealthy endothelium or Descemet membrane. 1

3 DSEK for correcting ectatic disorder. Corneal transplants are considered outpatient procedures and do not require an inpatient stay (InterQual Clinical Guidelines, 2017). Potentially recurrent disease is not a contraindication to keratoplasty, but the risks of corneal perforation from the disease and recurrent infection of donor tissue must be carefully considered prior to surgery. For Medicare members only: Keratoplasty procedures primarily for refractive correction and radial keratotomy are not covered by Medicare (CMS Manual System, Pub , Medicare National Coverage Determinations Manual, Section 80.7, Refractive Keratoplasty). The CPT manual (at 65710) gives an instruction to use other codes for refractive keratoplasty, such as CPT codes 65760, 65765, and Alternative covered services: Conservative treatment designed to reduce the fluid accumulation in corneal degeneration, or treatment ordered by the treating specialist for a specific disorder. Phototherapeutic keratectomy (AAO, 2017). Background The cornea forms the transparent anterior part of the eye. It protects the contents of the eye and serves as the major refractive element in it. The principal layers of the cornea are the epithelium, Bowman s layer, stroma, Descemet s membrane, and the endothelium (National Eye Institute [NEI], 2016). Corneal eye disease is the fourth most common cause of blindness (after cataracts, glaucoma, and agerelated macular degeneration) and affects more than 10 million people worldwide (Wachler, 2015). Common causes of corneal disease include: corneal dystrophies (e.g., keratoconus, FECD, lattice dystrophy, and map-dot-fingerprint dystrophy); corneal scar with opacity; keratitis; corneal transplant rejection; corneal edema; and herpes simplex keratitis (Matthaei, 2017; NEI, 2016). An eye bank provides the donor tissue for corneal transplant surgery in the United States. Since 1961, more than 1.5 million people have had restored vision through corneal transplants (Eye Bank Association of America [EBAA], 2016). More than 95 percent of all corneal transplant operations successfully restore the corneal recipient s vision. The success of corneal transplantation may be attributed in part to the normal cornea lacking blood vessels, which may prevent the body from recognizing the foreign donor cornea (EBAA, 2016). Corneal transplant procedures: 2

4 Corneal transplants are performed on an outpatient basis under local anesthesia (NEI, 2016). The surgery involves using a cookie-cutter-like knife called a trephine to remove a circular piece from the recipient s scarred cornea and donor cornea, which is sewn into place with very fine sutures smaller in diameter than a human hair. PK involves the full-thickness resection of the cornea and is the standard surgical procedure for treating corneal opacities (NEI, 2016; Donaghy, 2015). Most PKs are performed to improve poor visual acuity caused by an opaque cornea. Surgically-induced astigmatism is a potential complication of PK that may require refractive surgery. Component (partial-thickness) LK replaces only the affected layer(s) of corneal tissue (Donaghy, 2015). Further advances have enabled surgeons to perform anterior lamellar, deep lamellar, and endothelial lamellar procedures. DALK is the most common and involves selective transplantation of the corneal stroma that leaves the native Descemet membrane and healthy endothelium in place. Disease processes that involve the stroma include corneal ectasia, corneal scars that are not full-thickness, and corneal stromal dystrophies. EK procedures are performed for treatment of corneal edema in the setting of endothelial dysfunction. DSAEK and DMEK involve selective removal of the Descemet membrane and endothelium. DMEK replaces the Descemet membrane and endothelium, while DSAEK involves replacing the recipient Descemet membrane, endothelium, and posterior stroma. DMEK involves less transplanted tissue and, consequently, minimal optical interface effects (Donaghy, 2015). Keratoprosthesis involves full-thickness removal of the cornea and replacement by an artificial cornea. The device can be used in situations in which other types of keratoplasty are not an option, but infection, device extrusion, and post-operative glaucoma are important complications (MEEI, 2017; Donaghy, 2015). Regulation: Surgical procedures are not subject to FDA regulation, but the FDA Center for Devices and Radiological Health (CDRH) does regulate instruments used during ophthalmic surgeries, including corneoscleral punches, trephines, forceps, hooks, retrobulbar needles, and others (CDRH, 2017). There is a large number of FDA-approved microkeratomes primarily for corneal dissection during (laser assisted in situ keratomileusis (LASIK) eye surgery, but the EK procedures are not specifically referenced in the approval documents (FDA, 2017a). The FDA Center for Biologics Evaluation and Research (CBER) regulates human cells or tissue intended for implantation, transplantation, infusion, or transfer into a human recipient including cells or tissue from the cornea (CBER, 2017). The FDA regulates keratoprostheses as Class II devices with special controls to provide a transparent optical pathway through an opacified cornea in an eye that is not a reasonable candidate for any form of corneal transplant, including PK (21CFR ). The FDA has 3

5 approved three keratoprostheses for commercial use, and the Boston Type I KPro is the most commonly used in the United States (FDA, 2017b; Donaghy, 2015). Searches AmeriHealth Caritas Pennsylvania HealthChoices searched PubMed and the databases of: UK National Health Services Centre for Reviews and Dissemination. Agency for Healthcare Research and Quality s National Guideline Clearinghouse and other evidence-based practice centers. The Centers for Medicare & Medicaid Services (CMS). We conducted searches on October 20, Search terms were: Corneal Transplantation (MeSH), Descemet Stripping Endothelial Keratoplasty (MeSH), Keratoplasty, Penetrating (MeSH), and free text terms corneal transplants, descemet stripping, endothelial keratoplasty, and endothelial dysfunctions. We included: Systematic reviews, which pool results from multiple studies to achieve larger sample sizes and greater precision of effect estimation than in smaller primary studies. Systematic reviews use predetermined transparent methods to minimize bias, effectively treating the review as a scientific endeavor, and are thus rated highest in evidence-grading hierarchies. Guidelines based on systematic reviews. Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple cost studies), reporting both costs and outcomes sometimes referred to as efficiency studies which also rank near the top of evidence hierarchies. Findings FECD and keratoconus are the primary indications for corneal transplantation among the elderly and adolescents, respectively (Duman, 2013; Lowe, 2011). Keratoplasty for FECD is typically reserved until a patient experienced a significant, persistent decrease in vision throughout the day, not simply in the morning, when the cornea is most swollen. Keratoplasty for keratoconus in adolescents show excellent survival (Lowe, 2011). Seventy-five percent of patients achieved 20/40 vision or better (some needed eyeglasses, contact lenses, or vision-correcting surgery) and 90 percent still had viable corneas at their 10-year follow-up. However, less than 40 percent of infants (< age 5 years) had functional corneas at 16 years post-surgery, compared with 70 percent in the 5 12 year age group, at 22 years post-surgery. Corneal graft survival and visual outcomes varied more by indication for graft than recipient age, but presence of serious developmental disorders may have affected results. The most suitable surgical candidates for EK would be patients with FECD or pseudophakic bullous keratopathy. EK may also be valuable for some patients with a failed PK, particularly those without 4

6 significant stromal scarring, opacification, or vascularization of the anterior layers. Pseudophakic patients with deep anterior chambers and posterior chamber intraocular lenses are the best candidates for the novice surgeon, as there is adequate space to unfold the donor button without risk of trauma to the lens. Similarly, for patients requiring both corneal transplantation and cataract removal, it is advantageous to perform a triple procedure with removal of the cataract just before the EK portion of the surgery. This allows the creation of a deeper anterior chamber and avoids the risk of damaging the donor graft. No RCTs were found that directly compared DSEK or DSAEK with the reference standard of care, PK, or with other EK techniques. Hayes (2011) reviewed seven studies, including three comparative trials that evaluated the efficacy and safety of DSAEK and DSEK. DSAEK and DSEK improve visual acuity in the short term with little effect on refractive astigmatism, although they are associated with mild hyperopic shifts. Improvements in best-corrected visual acuity were achieved more quickly following DSAEK and DSEK compared with PK, although the results of the two surgery types appear similar after one year. Complication rates of dislocation following Descemet stripping procedures ranged from 2.6 percent to 23.0 percent, and graft failure rates ranged from 0 to 18 percent. Variation in surgical technique and expertise complicated data interpretation. While promising, the long-term efficacy and safety of Descemet stripping procedures compared with PK have not been established. There is insufficient evidence to determine whether automating the procedure, using precut versus fresh, surgeon-cut corneal grafts, or the presence of ECD of the donor cornea influences outcomes. Variation in surgical technique and expertise between the studies further complicates data interpretation. Definitive answers await the performance of RCTs with blinded assessment of health outcomes (Hayes, 2011). The main benefits of EK include a stronger wound (absence of a full thickness incision), more rapid healing, and little or no change in refraction. Since the anterior layers remain undisturbed, there is no need for the use of surface corneal sutures, as for traditional PK. The corneal curvature also remains more stable over time and the large shifts in refraction that sometimes occur with corneal grafts do not occur. Late suture-related complications, such as infection or vascularization, are prevented and the absence of a full-thickness vertical interface in the cornea increases the safety of the procedure, both during and after the operation. The absence of penetrating corneal sutures and incisions results in reduced postoperative astigmatism, normal corneal topography, faster wound healing, earlier visual rehabilitation, and a more stable globe. In addition, rejection appears to be less frequent during the first two years after EK, and may be less severe after EK than after PK. Should rejection occur, aggressive treatment may be considered, as for conventional PK. The minimal alteration in the contour of the cornea after surgery means that the predictability of intraocular lens power calculations is enhanced. For DSEK, the entire recipient cornea is left intact; thus, subsequent LASIK or other procedures may still be applied. In areas where donor grafts are scarce, the benefit of 5

7 multiple recipients for one donated eye is also important. The main disadvantages to EK include the need for specific instrumentation, a steeper learning curve, and the need for excellent surgical technique. EK requires a different skill set than that required for standard full thickness PK, so experienced PK surgeons may initially find the EK maneuvers awkward and unfamiliar. It is strongly recommended that EK should be extensively practiced in the laboratory before embarking on clinical treatment of patients. Policy updates: In 2017, we added two evidence-based guidelines (AAO, 2017; AAO, 2013) and three systematic reviews and meta-analyses (Deng, 2017; Ahmad, 2016; Lee, 2015) to the policy. PK, LK, and EK procedures are effective for treating corneal opacities and edema. The preferred technique continues to evolve, and choice will depend on: the presence and extent of subepithelial or stromal scarring; the potential impact of ocular surface disease on epithelial healing and stability; and the extent of any reconstructive intraocular surgery that might be necessary at the time of surgery (AAO, 2017; AAO, 2013). New information supports the safety and efficacy of the Boston KPro as a treatment alternative for adult patients with donor corneal graft failure and poor prognosis for further grafting, as it confers a greater likelihood of maintaining visual improvement without a higher risk of postoperative glaucoma; the evidence is insufficient to support its use in persons younger than age 18 years (Ahmad, 2016; Lee, 2015). The developers of the Boston KPro list vision less than 20/200 in the affected eye and compromised vision in the opposite eye and no end-stage glaucoma or retinal detachment as additional criteria for use (MEEI, 2017). The Boston KPro was added to the list of corneal transplant procedures. Summary of clinical evidence: Citation AAO (2017) Content, Methods, Recommendations Key points: Guideline: Cornea/External Disease Summary Benchmarks Consider LK using DALK techniques for progressive keratoconus without significant scarring or hydrops (High-quality systematic reviews of case-control or cohort studies or high-quality case-control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal [II++], moderate-quality evidence [MQ], discretionary recommendation [DR]). Consider crescentic LK when maximal thinning is in the cornea s periphery. (Nonanalytic studies [III], insufficient quality [IQ], DR). Recommend standard decentered LK for tectonic support followed by a central PK later for peripheral thinning and ectasia (III, IQ, DR). Recommend PK when a patient can no longer achieve functional vision with eyeglasses or contact lenses, or persistent corneal edema occurs following hydrops (III, IQ, DR). Recommend against DSEK to correct ectatic disorder. (III, IQ, DR). Prefer PK over DALK in cases of deep stromal scarring. (III, IQ, DR). Consider corneal edema and persistent discomfort, but limited or no visual potential, as better candidates for the following procedures: - Phototherapeutic keratectomy (III, IQ, DR) 6

8 Citation Deng (2017) for the AAO DMEK: safety and outcomes Ahmad (2016) Boston Type 1 KPro v. repeat PK for corneal graft failure Lee (2015) for the AAO Boston KPro: outcomes and complications ophthalmic technology assessment Content, Methods, Recommendations - Conjunctival flap of Gunderson (III, IQ, DR) - Corneal transplantation. - EK. - PK (III, good-quality [GQ], SR). Recommend superficial keratectomy, LK, PK, and keratoprosthesis for anterior corneal lesions extending beyond Bowman s layer into the anterior and midstroma for more extensive treatment (III, GQ, SR). Key points: Systematic review of two RCTs, 15 case-control and cohort studies or RCTs with substantial methodologic deficits, 15 low-quality observational studies. Evidence suggests DMEK is superior to DSEK in achieving a faster visual recovery, a better visual outcome, and a lower immune rejection rate; DMEK induces less refractive error than DSEK. DMEK and DSEK offer comparable rates of endothelial cell loss, primary and secondary graft failure rate, and perioperative complications, but insufficient comparative evidence of long-term graft survival beyond five years. DMEK is more technically challenging and could involve a higher rate of air injection than in DSEK during the early part of the learning curve. DSEK is preferred for treating endothelial dysfunction with abnormal anatomy, such as those with an anterior chamber intraocular lens, large iris defect, or absence of lens support. Key points: Systematic review and meta-analysis of 21 case series and 5 cohort studies, along with a comparison of results to a retrospective review of consecutive, nonrandomized, longitudinal case series of KPro implantations performed at five U.S. tertiary care centers. Probability of maintaining 20/200 or better at two years: repeat PK = 42% (95% confidence interval [CI] 30% - 56%) v. KPro = 80% (95% CI 68% - 88%). Probability of maintaining a clear graft at five years: repeat PK 47% (95% CI 40% - 54%) v. KPro = 75% (95% CI 64% - 84%). Rate of progression of glaucoma at three years: repeat PK = 25% (95% CI 10% - 44%) v. KPro = 30%. Key points: Systematic review of nine well-designed case-control and cohort studies, and RCTs with substantial methodologic deficits, that included at least 25 eyes. Overall quality: moderate with moderate risk of bias. Follow-up time: 8.5 to 21 months in six of nine studies, longest follow-up was 47 months in one study. Outcomes and complications worsened with increased follow-up time. A best-corrected Snellen visual acuity (BCSVA) of 20/200 or better occurred in 45% to 89% of eyes. Retention rates ranged from 65% to 100%. Most common post-surgical complications were retroprosthetic membrane formation and glaucoma, followed by corneal melts and infectious keratitis. Posterior segment complications were less common than anterior segment complications. Higher rates of severe, devastating complications in patients with autoimmune conditions and conditions associated with neurotrophic corneas and chronicepithelial. Insufficient data in children. 7

9 Citation AAO (2013) Content, Methods, Recommendations Key points: Guideline: AAO Cornea/External Disease Preferred Practice Pattern Indications for keratoplasty: 1) managing corneal opacification or edema if significant tissue thickness is involved; 2) when the endothelium is compromised and unresponsive to conservative measures. EK has supplanted PK as the procedure of choice in cases of endothelial failure in the absence of corneal scarring because patients achieve more rapid visual astigmatism, significantly reduced risk of postkeratoplasty astigmatism, suturerelated infections, and traumatic wound rupture. The preferred technique continues to evolve and depend on several factors: - Presence and extent of subepithelial or stromal scarring. - Potential impact of ocular surface disease on epithelial healing and stability. - Extent of any reconstructive intraocular surgery that might be necessary at the time of surgery. - For EK, prior posterior vitrectomy, aphakia, filtering or shunt surgery for glaucoma, extensive posterior synechiae, and a shallow anterior chamber can impact effectiveness. References Professional society guidelines/other: AAO Cornea/External Disease Summary Benchmarks Preferred Practice Pattern Guidelines June AAO website. Accessed October 22, AAO Corneal Edema and Opacification PPP AAO website. Accessed October 23, InterQual Procedures Clinical Guidelines McKesson Corporation. National Institute for Health and Clinical Excellence (NICE) Interventional Procedures Programme. Interventional Procedure Overview of Corneal Implants for Keratoconus NICE website. Accessed October 23, NICE Guidance. Corneal implants for keratoconus. Interventional procedure guidance 227. Published: 25 July Updated 14 January NICE website Accessed October 23, Peer-reviewed references: 21CFR

10 Donaghy CL, Vislisel JM, Greiner MA. An Introduction to Corneal Transplantation. May 21, University of Iowa Health Care website. Accessed October 20, Duman F, Kosker M, Suri K, et al. Indications and Outcomes of Corneal Transplantation in Geriatric Patients. Am J Ophthal. 2013; 156(3): EBAA Statistical Report EBAA website. Accessed October, 20, FDA 510(k) Premarket Notification database searched using product code HNO. FDA website. Accessed October 20, 2017.(a) FDA 510(k) Premarket Notification database search using product code HQM. FDA website. Accessed October 22, 2017.(b) FDA CBER. Tissue and tissue products. Updated December 29, FDA website. Assessed October 20, FDA CDRH. Medical devices. FDA website. Accessed October 20, Hayes Inc. Hayes Medical Technology Report. Descemet stripping with Manual or Automated Endothelial Keratoplasty for Corneal Endothelial Degeneration. Hayes, Inc.; Lansdale, Pa. March Lowe MT, Keane MC, Coster DJ, Williams KA. The outcome of corneal transplantation in infants, children, and adolescents. Ophthalmology Mar; 118(3): National Eye Institute. Facts About the Cornea and Corneal Disease. Last reviewed May NEI website. Accessed October 20, Terry MA, Ousley PJ. Deep lamellar endothelial keratoplasty (DLEK): early complications and their management. Cornea. 2006; 25: Wachler BB. Cornea Transplants: What to Expect. Allaboutvision.com website. Accessed October 23, CMS National Coverage Determinations (NCDs): 80.7 Refractive Keratoplasty. CMS website. Accessed October 23,

11 Local Coverage Determinations (LCDs): No LCDs identified at the writing of this policy. Commonly submitted codes Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is not an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and bill accordingly. CPT Code Description Comments Keratoplasty (corneal transplant); anterior lamellar Keratoplasty (corneal transplant); penetrating except in aphakia or pseudophakia) Keratoplasty (corneal transplant); penetrating (in aphakia) Keratoplasty (corneal transplant); penetrating (in pseudophakia) Keratoplasty (corneal transplant); endothelial ICD-10 Code Description Comments E50.6 Vitamin A deficiency with xerophthalmic scars of cornea H17.89 Other corneal scars and opacities H17.9 Unspecified corneal scar and opacity H Unspecified corneal deposit, right eye H Unspecified corneal deposit, left eye H Unspecified corneal deposit, bilateral H Unspecified corneal deposit, unspecified eye H Unspecified corneal deposit, unspecified eye H18.20 Unspecified corneal edema H18.20 Unspecified corneal edema H Idiopathic corneal edema, right eye H Idiopathic corneal edema, right eye H Idiopathic corneal edema, left eye H Idiopathic corneal edema, bilateral H Idiopathic corneal edema, unspecified eye H Secondary corneal edema, right eye H Secondary corneal edema, left eye H Secondary corneal edema, bilateral H Secondary corneal edema, unspecified eye H18.50 Unspecified hereditary corneal dystrophies H18.51 Endothelial corneal dystrophy H18.52 Epithelial (juvenile) corneal dystrophy H18.53 Granular corneal dystrophy H18.54 Lattice corneal dystrophy H18.55 Macular corneal dystrophy H18.59 Other hereditary corneal dystrophies H Keratoconus, unspecified, right eye 10

12 ICD-10 Code Description Comments H Keratoconus, unspecified, left eye H Keratoconus, unspecified, bilateral H Keratoconus, unspecified, unspecified eye H Keratoconus, unstable, right eye H Keratoconus, unstable, left eye H Keratoconus, unstable, bilateral H Keratoconus, unstable, unspecified eye H Anesthesia and hypoesthesia of cornea, right eye H Anesthesia and hypoesthesia of cornea, left eye H Anesthesia and hypoesthesia of cornea, bilateral H Anesthesia and hypoesthesia of cornea, unspecified eye L76.81 Other intraoperative complications of skin and subcutaneous tissue L76.82 Other postprocedural complications of skin and subcutaneous tissue T26.11XA Burn of cornea and conjunctival sac, right eye, initial encounter T26.12XA Burn of cornea and conjunctival sac, left eye, initial encounter T26.60XA Corrosion of cornea and conjunctival sac, unspecified eye, initial encounter T26.61XA Corrosion of cornea and conjunctival sac, right eye, initial encounter T26.62XA Corrosion of cornea and conjunctival sac, left eye, initial encounter T85.318A Breakdown (mechanical) of other ocular prosthetic devices, implants and grafts, initial encounter T85.328A Displacement of other ocular prosthetic devices, implants and grafts, initial T85.398A encounter Other mechanical complication of other ocular prosthetic devices, implants and grafts, initial encounter T Corneal transplant rejection T Corneal transplant failure HCPCS Level II Code L8609 C1818 Description Artificial cornea Integrated keratoprosthesis Comments 11