Clinical Policy Title: Therapeutic contact lenses

Clinical Policy Title: Therapeutic contact lenses Clinical Policy Number: 10.02.02 Effective Date: June 1, 2014 Initial Review Date: December 18, 2013 Most Recent Review Date: January 20, 2016 Next Review Date: January 2017 Related policies: Policy contains: Hydrophilic contact lens for corneal bandage. Boston scleral lens (BSL). Scleral shell lens. Amniotic membrane transplantation (AMT). None. ABOUT THIS POLICY: AmeriHealth Caritas Pennsylvania has developed clinical policies to assist with making coverage determinations. AmeriHealth Caritas Pennsylvania s 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 peerreviewed 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 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 s 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 s clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, AmeriHealth Caritas Pennsylvania will update its clinical policies as necessary. AmeriHealth Caritas Pennsylvania s clinical policies are not guarantees of payment. Coverage policy AmeriHealth Caritas Pennsylvania considers the use of therapeutic contact lenses to be clinically proven and, therefore, medically necessary when all of the following criteria are met: Use of any of the following lens types: o Contact lenses or intra-ocular lenses placed after cataract surgery, as they are considered prostheses unless otherwise specified by the member s benefit plan. o Hydrophilic soft contact lenses or gas-permeable fluid ventilated scleral lenses, when used in the management of severe corneal disease. o Boston scleral lens (BSL) when used as a moist corneal bandage if lubricants or drops are not appropriate. o Scleral shell contact lenses for the treatment of severe keratoconjunctivitis sicca and/or when the orbit requires greater support because of the loss of corneal strength. Any of the following functional impairments are being corrected: 1

o o o Not able to achieve vision of 20/40 or better, despite best correction with eyeglasses or typical contact lenses. Lenses will delay/prevent the need for corneal transplantation. Will improve performance of activities of daily living (ADL). Limitations: All other uses of therapeutic contact lenses are not medically necessary. Contact lenses for vision correction are subject to benefit plans of the individual member. The use of contact lenses for treatment of visual perceptual dysfunction, such as dyslexia, has not had consistent results in clinical studies and cannot be considered medically necessary. AMT has insufficient evidence in the peer-reviewed medical literature to support its use over standard care. For Medicare members only: For services performed on or after October 1, 2015, AMT for ocular conditions will be considered medically reasonable and necessary for the following indications: Failure of standard therapy for severe ophthalmological conditions demonstrated by ocular surface cell damage or failure and/or underlying inflammation, scarring, or ulceration of the underlying stroma. There may be circumstances where there is a severe condition requiring acute treatment with amniotic membrane (AM), such as: o Chemical, thermal or radiation injuries. o Stevens Johnson Syndrome. o Limbal stem cell failure. Band keratopathy after treatment with other therapy, such as: o Surgery. o Topical medications o Bandage contact lens. o Patching. Bullous keratopathy associated with an epithelial defect. Scleral melting. Corneal ulcer following initiation of anti-infective therapy and demonstration of clinical response for the purpose of healing the persistent epithelial defect. Chemical burns of the ocular surface. Conjunctival defects after treatment with other therapy, such as surgery or topical medications. Corneal melting. Limbal stem cell deficiency (LSCD). Recurrent corneal erosions after treatment failure with other therapy, such as: o Bandage contact lens. 2

o o Patching. Topical medications. Limitations for Medicare members only: AM must have U.S. Food and Drug Administration (FDA) approval for sutureless applications to eye. Application for dry eye syndrome is noncovered, given no demonstrated impact on long-term outcome. Cogan s Dystrophy is noncovered unless associated with corneal epithelial removal. Alternative covered services: Physician office visits. Standard covered ocular surgery. Standard medical management of corneal disease. Background Corneal pathology may cause correctable vision distortion, pain, or threaten sight. Vision may be corrected by the use of refractive eyeglasses or contact lenses. These lenses are primarily used for correction of myopia, hypermetropia, astigmatism, and presbyopia, and as such, are a cosmetic substitute for eyeglasses. Refracting contact lenses may be rigid/hard lens, soft (hydrophilic, hydrogel and silicone hydrogel) or gas permeable rigid lens. Therapeutic contact lenses are designed to manage other ocular pathology beyond simple refractive disorders. The corneal disorders for which contact lenses become therapeutic, include the following conditions: Aphakia. Prostheses following cataract surgery. Stevens-Johnson syndrome, Toxic Epidermolysis Necrosis (TEN), chemical burns or other corneal stem cell deficiencies. Congenital anomalies. Neurotrophic corneas. Keratoconjunctivitis with reduced tear production. Corneal involvement of systemic autoimmune disorders. Corneal exposure disorders. Epidermal ocular disorders. Keratoconus associated with irregular astigmatism. 3

There are several types of therapeutic lenses available for the management of these disorders. The use of various lens options have not been standardized through randomized controlled trials (RCTs), but there is a general standard accepted for their use: Corneal liquid bandage lens These may be rigid gas permeable (RGP) scleral contact lenses or a therapeutic contact lens. They are used to treat acute or chronic corneal disease, such as the persistent epithelial defects listed above. These lenses protect the cornea from the drying effects of air and may reduce pain and photophobia. Because such lenses cover the entire cornea with a smooth surface, they may improve vision that results from acute astigmatism. BSL This lens was developed through the Boston Foundation for Sight. It is a specially designed fluid-ventilated, gas-permeable contact lens. The design allows a bubble-free reservoir of oxygenated aqueous fluid to cover the corneal surface, at a neutral hydrostatic pressure. This design makes it well suited for severe corneal diseases. Scleral shell contact lens Unlike other types of lens, the scleral shell contact lens covers the entire exposed surface of the eye. For individuals with severe dry eye, such as keratoconjunctivitis, the scleral shell lens can hold artificial tears that have been dropped into the eye. These lenses protect the eye against further drying. The scleral shell also allows support and protection when severe corneal disease has rendered the person blind. Use of the scleral shell may prevent enucleation by providing support for the rest of the eye. AMT Rather than provide a contact lens in cases of severe thermal or chemical burns to the cornea, AM may be transplanted to the area of burn to reduce pain and accelerate healing. Searches AmeriHealth Caritas Pennsylvania 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 December 8, 2013, December 10, 2013, January 4, 2015 and November 20, 2015. Search terms were: therapeutic contact lenses and amniotic membrane. 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. 4

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 Most studies on the various medical uses of contact lenses have been single site, with relatively small numbers enrolled. We found no recent meta-analyses of therapeutic contact lenses or head-to-head comparisons between the various products. Reviews of studies of AMT have not found sufficient evidence from published, peer-reviewed articles to support its use (Clare, 2012; Hayes, 2013). Professional guidelines from the American Academy of Ophthalmology (AAO) note the absence of such studies and recommend that the professional describe the advantages of various strategies, thus allowing the patient to be an active participant in the clinical judgment. There is consensus that patients with corneal pathology that threatens to weaken the architecture of the eye should be treated with appropriate medical therapy and/or supporting contact lenses. Policy updates: We found one new systematic review that addressed ex vivo cultured limbal epithelial transplantation (CLET) with AMT for the treatment of LSCD (Zhao, 2015). We found one ongoing clinical trial of AMT that has been in progress since the year 2000, but has not been verified since 2008, and no published results of the study are available (ClinicalTrials.gov identifier: NCT00344708). Since the last review date of this policy, the AAO has updated three Preferred Practice Pattern guidelines: corneal edema and opacification; corneal ectasia; and dry eye syndrome. The new information does not impact the results of the original clinical policy. Therefore, no changes to the policy are warranted. Summary of clinical evidence: Citation Zhao (2015) AMT Content, Methods, Recommendations Key points: Systematic review of 18 articles involving 572 eyes of 562 patients who underwent ex vivo CLET with AM for treatment of LSCD. The rate of success and 2-line improvement in best corrected visual acuity (BCVA) was 67% [95% confidence interval (CI), 0.59-0.75; I = 60%] and 62% (95% CI, 0.57-0.66; I = 37.7%), respectively; and no difference was found either in success rate [odds ratio (OR), 1.35; 95% CI, 0.63-2.89; I = 46%] or visual acuity (VA) outcome (OR, 1.53; 95% CI, 0.67-3.45; I = 42.1%) between autograft and allograft. CLET appears efficacious in patients with LSCD. Acceptable safety profile with most side effects being transient and amenable to subsequent treatments. Long-term results of autograft and allograft are needed to inform future treatment algorithms and techniques with RCTs and better-designed analysis. 5

Citation Watson (2012) Content, Methods, Recommendations Key points: Management of recurrent corneal erosion Meta-analysis of seven RCTs and one quasi-rct. These various studies came to different independent conclusions regarding use of oral tetracycline, contact lenses or hypertonic saline ointment. The therapeutic contact lens arm had older rigid lenses and was less able to reduce pain or promote healing, compared to the oral tetracycline or hypertonic saline ointment. Hayes (2013) Key points: Boston Equalens scleral contact lens Meta-analysis of four uncontrolled studies, where the endpoints were not clear. The descriptions from the four studies were consistent with significant relief of pain, reduced photophobia and improved visual acuity. Clare (2012) Key points: Cochrane review AMT Systematic review found one RCT with 100 participants with ocular burns, comparing standard treatment to AMT. The study was flawed in that the control group had worse acuity at the start than did the AMT group. But the latter had better vision at the end. There is inadequate evidence supporting the treatment of ocular surface burns with AMT. CMS policies CMS National Coverage Determination (NCD) for Hydrophilic Contact Lens For Corneal Bandage (80.1) Policy Benefit category Incident to a physician's professional service. Outpatient hospital services incident to a physician's service. Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service. Item/service description Some hydrophilic contact lenses are used as moist corneal bandages for the treatment of acute or chronic corneal pathology, such as bullous keratopathy, dry eyes, corneal ulcers and erosion, keratitis, corneal edema, descemetocele, corneal ectasis, Mooren's ulcer, anterior corneal dystrophy, neurotrophic keratoconjunctivitis, and for other therapeutic reasons. Indications and Limitations of Coverage Payment may be made under 1861(s)(2) of the Act for a hydrophilic contact lens approved by the U.S. Food and Drug Administration (FDA) and used as a supply incident to a physician's service. Payment for the lens is included in the payment for the physician's service to which the lens is incident. Contractors are authorized to accept an FDA letter of 6

CMS Policy approval or other FDA published material as evidence of FDA approval. (See 80.4 of the NCD Manual for coverage of a hydrophilic contact lens as a prosthetic device.) National Coverage Determination (NCD) for hydrophilic contact lenses (80.4) Benefit category Prosthetic devices Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service. Indications and limitations of coverage Hydrophilic contact lenses are eyeglasses within the meaning of the exclusion in 1862(a)(7) of the Act and are not covered when used in the treatment of nondiseased eyes with spherical ametrophia, refractive astigmatism, and/or corneal astigmatism. Payment may be made under the prosthetic device benefit; however, for hydrophilic contact lenses when prescribed for an aphakic patient. Contractors are authorized to accept an FDA letter of approval or other FDA published material as evidence of FDA approval. (See 80.1 of the NCD Manual for coverage of a hydrophilic lens as a corneal bandage.) National Coverage Determination (NCD) for Scleral Shell (80.5) Benefit Category Prosthetic devices Item/service description Scleral shell (or shield) is a catchall term for different types of hard scleral contact lenses. Indications and limitations of coverage A scleral shell fits over the entire exposed surface of the eye, as opposed to a corneal contact lens that covers only the central non-white area, encompassing the pupil and iris. Where an eye has been rendered sightless and shrunken by inflammatory disease, a scleral shell may, among other things, obviate the need for surgical enucleation and prosthetic implant and act to support the surrounding orbital tissue. In such a case, the device serves essentially as an artificial eye. In this situation, payment may be made for a scleral shell under 1861(s)(8) of the Act. Scleral shells are occasionally used in combination with artificial tears in the treatment of "dry eye" of diverse etiology. Tears ordinarily dry at a rapid rate, and are continually replaced by the lacrimal gland. When the lacrimal gland fails, the half-life of artificial tears may be greatly prolonged by the use of the scleral contact lens as a protective barrier against the drying action of the atmosphere. Thus, the difficult and sometimes hazardous process of frequent installation of artificial tears may be avoided. The lens acts in this instance to substitute, in part, for the functioning of the diseased lacrimal gland and is covered as a prosthetic device in the rare case when it is used in the treatment of "dry eye." 7

CMS LCD for AM Sutureless Placement on the Ocular Surface (L36237). Policy For services performed on or after 10/01/2015 This LCD addresses limited indications of the suture less form of AM used as a biological corneal bandage. AMT for ocular conditions will be considered medically reasonable and necessary for the following indications: Failure of standard therapy for severe ophthalmological conditions demonstrated by ocular surface cell damage or failure and/or underlying inflammation, scarring, or ulceration of the underlying stroma. There may be circumstances where there is a severe condition requiring acute treatment with AM, such as: o Chemical, thermal or radiation injuries. o Stevens Johnson Syndrome. o Limbal stem cell failure. Band keratopathy after treatment with other therapy, such as: o Surgery. o Topical medications. o Bandage contact lens. o Patching. Bullous keratopathy associated with an epithelial defect. Scleral melting. Corneal ulcer following initiation of anti-infective therapy, and demonstration of clinical response for the purpose of healing the persistent epithelial defect. Chemical burns of the ocular surface. Conjunctival defects after treatment with other therapy, including surgery or topical medications. Corneal melting. LSCD. Recurrent corneal erosions after treatment failure with other therapy, such as: o Bandage contact lens. o Patching. o Topical medications. Limitations: AM must have FDA approval for sutureless applications to eye. Application for dry eye syndrome is noncovered, given no demonstrated impact on long-term outcome. Cogan s Dystrophy is noncovered, unless associated with corneal epithelial removal. Following surgery/within global period: Use of AM within the postoperative period of a prior surgery, not requiring a return to the operating room, and not pre-planned, is subject to the principles for global surgery defined in Medicare Claims Processing Manual, Chapter 12, 40, and will not be reimbursed separately. 8

Glossary Cornea The thin transparent covering over the anterior portion of the eye. The cornea covers the iris, pupil, and anterior chamber of the eye. Corneal ectasia A non-inflammatory progressive steepening and thinning of the cornea. This may include keratoconus, pellucid marginal degeneration, keratoglobus, postkeratorefractive ectasia, and wound ectasia. Keratoconjunctivitis sicca Condition known as dry eye syndrome or xerophthalmia that is caused by reduced tear production or excessive tear evaporation. Lens The biconvex structure in the eye through which light entering the eye is focused on the retina for vision. Limbus The border of the cornea that is continuous with the sclera. Visual perceptual dysfunctions A visual distortion caused by sensitivities to particular wavelengths of light. Source in public domain: http://en.wikipedia.org/wiki/file:cornea.png 9

References Professional society guidelines/other: American Academy of Ophthalmology Cornea/External Disease Panel. Preferred Practice Pattern Guidelines. Corneal Edema and Opacification Summary Benchmarks 2014. American Academy of Ophthalmology (AAO) website. http://www.aao.org/summary-benchmark-detail/corneal-edemaopacification-summary-benchmark--2014. Accessed November 20, 2015. American Academy of Ophthalmology Cornea/External Disease Panel. Preferred Practice Pattern Guidelines. Corneal Ectasia 2014. AAO website. http://www.aao.org/summary-benchmarkdetail/corneal-ectasia-summary-benchmark--2013. Accessed November 20, 2015. American Academy of Ophthalmology. Preferred Practice Pattern Guidelines. Dry Eye Syndrome. AAO website. http://www.aao.org/summary-benchmark-detail/dry-eye-syndrome-summary-benchmark-- october-2012. Accessed November 20, 2015. American Academy of Pediatrics, Section on Ophthalmology, Council on Children with Disabilities, AAO, American Association for Pediatric Ophthalmology and Strabismus and American Association of Certified Orthoptists. Learning Disabilities, Dyslexia, and Vision. Pediatrics 2009 Aug; 124(2); 837 44. Also available at: http://pediatrics.aappublications.org/content/124/2/837.long. Accessed November 20, 2015. Peer-reviewed references: Clare G, Suleman H, Bunce C, Dua H. Amniotic membrane transplantation for acute ocular burns. Cochrane Database Syst Rev. 2012 Sep 12; 9: CD009379. Foulks GN, Harvey T, Raj CV. Therapeutic contact lenses: the role of high-dk lenses. Ophthalmol Clin North Am. 2003 Sep; 16(3): 455 461. Hayes Inc. Hayes Medical Technology Report. Boston Equalens Scleral Contact Lens (Polymer Technology Corp.) for Severe Ocular Surface Disease. Lansdale, Pa: Hayes Inc.; October, 2006. Hayes Inc. Hayes Medical Technology Report. ProKera (Bio-Tissue Inc.) for the treatment of corneal ulcers. Lansdale, Pa: Hayes Inc.; January, 2013. Jacobs DS, Rosenthal P. Boston scleral lens prosthetic device for treatment of severe dry eye in chronic graft-versus-host disease. Cornea. 2007 Dec; 26(10): 1195 1199. Maissa C, Guillon M, Cockshott N, et al. Contact lens lipid spoliation of hydrogel and silicone hydrogel lenses. Optometry and Vision Science: official publication of the American Academy of Optometry. 2014; 91(9): 1071 1083. 10

Szczotka-Flynn L, Diaz M. Risk of corneal inflammatory events with silicone hydrogel and low dk hydrogel extended contact lens wear: a meta-analysis. Optom. Vis Sci. 2007 Apr; 84(4): 247 256. Watson SL, Lee MH, Barker NH. Interventions for recurrent corneal erosions. The Cochrane Database of Systematic Reviews. 2012; 9: CD001861. Zhao Y, Ma L. Systematic review and meta-analysis on transplantation of ex vivo cultivated limbal epithelial stem cell on amniotic membrane in limbal stem cell deficiency. Cornea. 2015; 34(5): 592 600. Clinical trials: Searched clinicaltrials.gov on January 4, 2015 using terms for hydrophilic contact lens OR corneal bandage OR boston scleral lens OR scleral shell lens or amniotic membrane Open Studies ocular OR cornea OR eye. 33 studies found, two relevant. Shunt Tube Exposure Prevention Study. ClinicalTrials.gov website. https://clinicaltrials.gov/show/nct01551550. Published March 8 2012. Updated November 5, 2015. Accessed November 20, 2015. Transplantation of Tissue Cultured Human Amniotic Epithelial Cells Onto Damaged Ocular Surfaces. ClinicalTrials.gov website. https://clinicaltrials.gov/show/nct00344708. Published June 23, 2006. Updated June 19, 2008. Accessed November 20, 2015. CMS National Coverage Determinations (NCDs): NCD for Hydrophilic Contact Lens for Corneal Bandage (80.1). CMS website. http://cms.hhs.gov/medicarecoverage-database/details/ncddetails.aspx?ncdid=136&ncdver=1&docid=80.1&bc=gaaaaagaaaaaaa%3d%3d&. Accessed November 20, 2015. NCD for Scleral Shell (80.5). CMS website. http://www.cms.gov/medicare-coverage-database/details/ncddetails.aspx?ncdid=235&ncdver=1&bc=aaaaqaaaaaaa&. Accessed November 20, 2015. NCD for Refractive Keratoplasty (80.7). CMS website. http://cms.hhs.gov/medicare-coveragedatabase/details/ncddetails.aspx?ncdid=72&ncdver=1&docid=80.7&kq=true&kq=true&bc=gaaaaagaaaaaaa%3d%3d&. Accessed November 20, 2015. Local Coverage Determinations (LCDs): LCD for Amniotic Membrane- Sutureless Placement on the Ocular Surface (L36237). CMS website. https://www.cms.gov/medicare-coverage-database/details/lcddetails.aspx?lcdid=36237&contrid=368&ver=3&contrver=1&searchtype=advanced&coverageselection=b 11

oth&ncselection=nca%7cncd%7cta%7cmcd&policytype=final&s=all&keyword=contact+lens&keyword LookUp=Doc&KeyWordSearchType=Exact&kq=true&bc=IAAAABAAAAAAAA%3d%3d&. Accessed November 20, 2015. 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 92071 Fitting of contact lens for treatment of ocular surface disease 92072 Fitting of contact lens for management of keratoconus; initial fitting 92310 Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation, corneal lens, both eyes, except for aphakia 92311 Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens for aphakia, 1 eye 92312 Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens for aphakia, both eyes 92313 Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneoscleral lens 92314 Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and direction of fitting by independent technician; corneal lens, both eyes except for aphakia 92315 Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and direction of fitting by independent technician; corneal lens for aphakia, 1 eye 92316 Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and direction of fitting by independent technician; corneal lens for aphakia, both eyes 92317 Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and direction of fitting by independent technician; corneoscleral lens 92325 Modification of contact lens (separate procedure), with medical supervision of adaptation 92326 Replacement of contact lens 12

ICD-10 Code Description Comments B55.2 Mucocutaneous leishmaniasis H02.051 Trichiasis without entropian right upper eyelid H02.052 Trichiasis without entropian right lower eyelid H02.053 Trichiasis without entropian right eye, unspecified eyelid H02.054 Trichiasis without entropian left upper eyelid H02.055 Trichiasis without entropian left lower eyelid H02.056 Trichiasis without entropian left eye, unspecified eyelid H02.059 Trichiasis without entropian unspecified eye, unspecified eyelid H02.89 Other specified disorders of eyelid H02.9 Unspecified disorder of eyelid H04.121 Dry eye syndrome of right lacrimal gland H04.122 Dry eye syndrome of left lacrimal gland H04.123 Dry eye syndrome of bilateral lacrimal glands H04.129 Dry eye syndrome of unspecified lacrimal gland H04.141 Primary lacrimal gland atrophy, right lacrimal gland H04.142 Primary lacrimal gland atrophy, left lacrimal gland H04.143 Primary lacrimal gland atrophy, bilateral lacrimal glands H04.149 Primary lacrimal gland atrophy, unspecified lacrimal gland H04.151 Secondary lacrimal gland atrophy, right lacrimal gland H04.152 Secondary lacrimal gland atrophy, left lacrimal gland H04.153 Secondary lacrimal gland atrophy, bilateral lacrimal glands H04.159 Secondary lacrimal gland atrophy, unspecified lacrimal gland H04.69 Other changes of lacrimal passages H10.211 Acute toxic conjunctivitis, right eye H10.212 Acute toxic conjunctivitis, left eye H10.213 Acute toxic conjunctivitis, bilateral H10.219 Acute toxic conjunctivitis, unspecified eye H10.89 Other conjunctivitis H11.241 Scarring of conjunctiva, right eye H11.242 Scarring of conjunctiva, left eye H11.243 Scarring of conjunctiva, bilateral H11.249 Scarring of conjunctiva, unspecified eye H16.121 Filamentary keratitis, right eye H16.122 Filamentary keratitis, left eye H16.123 Filamentary keratitis, bilateral H16.129 Filamentary keratitis, unspecified eye H16.141 Punctate keratitis, right eye H16.142 Punctate keratitis, left eye H16.143 Punctate keratitis, bilateral H16.149 Punctate keratitis, unspecified eye H16.211 Exposure keratoconjunctivitis, right eye H16.212 Exposure keratoconjunctivitis, left eye H16.213 Exposure keratoconjunctivitis, bilateral H16.219 Exposure keratoconjunctivitis, unspecified eye H16.221 Keratoconjunctivitis sicca, not specified as Sjogren's, right eye 13

H16.222 Keratoconjunctivitis sicca, not specified as Sjogren's, left eye H16.223 Keratoconjunctivitis sicca, not specified as Sjogren's, bilateral H16.229 Keratoconjunctivitis sicca, not specified as Sjogren's, unspecified eye H16.231 Neurotrophic keratoconjunctivitis, right eye H16.232 Neurotrophic keratoconjunctivitis, left eye H16.233 Neurotrophic keratoconjunctivitis, bilateral H16.239 Neurotrophic keratoconjunctivitis, unspecified eye H16.261 Vernal keratoconjunctivitis, with limbar and corneal involvement, right eye H16.262 Vernal keratoconjunctivitis, with limbar and corneal involvement, left eye H16.263 Vernal keratoconjunctivitis, with limbar and corneal involvement, bilateral Vernal keratoconjunctivitis, with limbar and corneal involvement, H16.269 unspecified eye H16.291 Other keratoconjunctivitis, right eye H16.292 Other keratoconjunctivitis, left eye H16.293 Other keratoconjunctivitis, bilateral H16.299 Other keratoconjunctivitis, unspecified eye H18.10 Bullous keratopathy, unspecified eye H18.11 Bullous keratopathy, right eye H18.12 Bullous keratopathy, left eye H18.13 Bullous keratopathy, bilateral H18.40 Unspecified corneal degeneration H18.411 Arcus senilis, right eye H18.412 Arcus senilis, left eye H18.413 Arcus senilis, bilateral H18.419 Arcus senilis, unspecified eye H18.421 Band keratopathy, right eye H18.422 Band keratopathy, left eye H18.423 Band keratopathy, bilateral H18.429 Band keratopathy, unspecified eye H18.43 Other calcerous corneal degeneration H18.441 Keratomalacia, right eye H18.442 Keratomalacia, left eye H18.443 Keratomalacia, bilateral H18.449 Keratomalacia, unspecified eye H18.451 Nodular corneal degeneration, right eye H18.452 Nodular corneal degeneration, left eye H18.453 Nodular corneal degeneration, bilateral H18.459 Nodular corneal degeneration, unspecified eye H18.461 Peripheral corneal degeneration, right eye H18.462 Peripheral corneal degeneration, left eye H18.463 Peripheral corneal degeneration, bilateral H18.469 Peripheral corneal degeneration, unspecified eye H18.49 Other corneal degeneration H18.51 Endothelial corneal dystrophy H18.53 Granular corneal dystrophy H18.54 Lattice corneal dystrophy H18.55 Macular corneal dystrophy H18.59 Other hereditary corneal dystrophies 14

H18.601 Keratoconus, unspecified, right eye H18.602 Keratoconus, unspecified, left eye H18.603 Keratoconus, unspecified, bilateral H18.609 Keratoconus, unspecified, unspecified eye H18.611 Keratoconus, stable, right eye H18.612 Keratoconus, stable, left eye H18.613 Keratoconus, stable, bilateral H18.619 Keratoconus, stable, unspecified eye H18.621 Keratoconus, unstable, right eye H18.622 Keratoconus, unstable, left eye H18.623 Keratoconus, unstable, bilateral H18.629 Keratoconus, unstable, unspecified eye H18.711 Corneal ectasia, right eye H18.712 Corneal ectasia, left eye H18.713 Corneal ectasia, bilateral H18.719 Corneal ectasia, unspecified eye H18.731 Descemetocele, right eye H18.732 Descemetocele, left eye H18.733 Descemetocele, bilateral H18.739 Descemetocele, unspecified eye H18.831 Recurrent erosion of cornea, right eye H18.832 Recurrent erosion of cornea, left eye H18.833 Recurrent erosion of cornea, bilateral H18.839 Recurrent erosion of cornea, unspecified eye L12.1 Cicatricial pemphigoid L12.30 Acquired epidermolysis bullosa, unspecified L12.31 Epidermolysis bullosa due to drug L12.35 Other acquired epidermolysis bullosa L51.0 Nonbullous erythema multiforme L51.1 Stevens-Johnson syndrome L51.2 Toxic epidermal necrolysis [Lyell] L51.3 Stevens-Johnson syndrome-toxic epidermal necrolysis overlap syndrome L51.8 Other erythema multiforme L51.9 Erythema multiforme, unspecified M35.00 Sicca syndrome, unspecified M35.01 Sicca syndrome with keratoconjunctivitis M35.02 Sicca syndrome with lung involvement M35.03 Sicca syndrome with myopathy M35.04 Sicca syndrome with tubulo-interstitial nephropa M35.09 Sicca syndrome with other organ involvement Q10.0 Congenital ptosis Q10.1 Congenital ectropion Q10.2 Congenital entropion Q10.3 Other congenital malformations of eyelid Q10.4 Absence and agenesis of lacrimal apparatus Q10.5 Congenital stenosis and stricture of lacrimal duct Q10.6 Other congenital malformations of lacrimal apparatus S00.201A Unspecified superficial injury of right eyelid and periocular area, initial 15

S00.202A S00.209A S00.211A S00.212A S00.219A S00.221A S00.222A S00.229A S00.241A S00.242A S00.249A S00.251A S00.252A S00.259A S00.261A S00.262A S00.269A S00.271A S00.272A S00.279A S05.00XA S05.01XA S05.02XA S05.20XA S05.21XA S05.22XA S05.30XA Unspecified superficial injury of left eyelid and periocular area, initial Unspecified superficial injury of unspecified eyelid and periocular area, initial Abrasion of right eyelid and periocular area, initial Abrasion of left eyelid and periocular area, initial Abrasion of unspecified eyelid and periocular area, initial Blister (nonthermal) of right eyelid and periocular area, initial Blister (nonthermal) of left eyelid and periocular area, initial Blister (nonthermal) of unspecified eyelid and periocular area, initial External constriction of right eyelid and periocular area, initial External constriction of left eyelid and periocular area, initial External constriction of unspecified eyelid and periocular area, initial Superficial foreign body of right eyelid and periocular area, initial Superficial foreign body of left eyelid and periocular area, initial Superficial foreign body of unspecified eyelid and periocular area, initial Insect bite (nonvenomous) of right eyelid and periocular area, initial Insect bite (nonvenomous) of left eyelid and periocular area, initial Insect bite (nonvenomous) of unspecified eyelid and periocular area, initial Other superficial bite of right eyelid and periocular area, initial Other superficial bite of left eyelid and periocular area, initial Other superficial bite of unspecified eyelid and periocular area, initial Injury of conjunctiva and corneal abrasion without foreign body, unspecified eye, initial Injury of conjunctiva and corneal abrasion without foreign body, right eye, initial Injury of conjunctiva and corneal abrasion without foreign body, left eye, initial Ocular laceration and rupture with prolapse or loss of intraocular tissue, unspecified eye, initial Ocular laceration and rupture with prolapse or loss of intraocular tissue, right eye, initial Ocular laceration and rupture with prolapse or loss of intraocular tissue, left eye, initial Ocular laceration without prolapse or loss of intraocular tissue, unspecified eye, initial 16

Ocular laceration without prolapse or loss of intraocular tissue, S05.30XA unspecified eye, initial Ocular laceration without prolapse or loss of intraocular tissue, right eye, S05.31XA initial Ocular laceration without prolapse or loss of intraocular tissue, left eye, S05.32XA initial Penetrating wound with foreign body of unspecified eyeball, initial S05.50XA S05.51XA Penetrating wound with foreign body of right eyeball, initial S05.52XA Penetrating wound with foreign body of left eyeball, initial Penetrating wound without foreign body of unspecified eyeball, initial S05.60XA S05.61XA Penetrating wound without foreign body of right eyeball, initial S05.62XA Penetrating wound without foreign body of left eyeball, initial encount S05.70XA Avulsion of unspecified eye, initial S05.71XA Avulsion of right eye, initial S05.72XA Avulsion of left eye, initial S05.8X1A Other injuries of right eye and orbit, initial S05.8X2A Other injuries of left eye and orbit, initial S05.8X9A Other injuries of unspecified eye and orbit, initial S05.90XA Unspecified injury of unspecified eye and orbit, initial S05.91XA Unspecified injury of right eye and orbit, initial S05.92XA Unspecified injury of left eye and orbit, initial T26.10XA Burn of cornea and conjunctival sac, unspecified eye, initial T26.11XA Burn of cornea and conjunctival sac, right eye, initial T26.12XA Burn of cornea and conjunctival sac, left eye, initial Corrosion of cornea and conjunctival sac, unspecified eye, initial T26.60XA T26.61XA Corrosion of cornea and conjunctival sac, right eye, initial T26.62XA Corrosion of cornea and conjunctival sac, left eye, initial Z94.7 Corneal transplant status HCPCS Level II S0515 V2530 V2531 Description Scleral lens, liquid bandage device, per lens Contact lens, scleral, gas impermeable, per lens Contact lens, scleral, gas permeable, per lens Comments 17