What is corneal collagen coss-linking for keratoconus?
Corneal collagen cross-linking (CXL) is a minimally invasive ophthalmic procedure designed to reinforce the structural integrity of the cornea, primarily to manage progressive keratoconus. Keratoconus weakens the cornea, leading to its thinning and an abnormal cone-like protrusion, which significantly distorts vision. The CXL procedure aims to halt or slow this progression by inducing the formation of new collagen cross-links within the corneal stroma. This is achieved by first saturating the cornea with riboflavin (vitamin B2) eye drops, which act as a photosensitizer. Subsequently, a controlled dose of ultraviolet-A (UV-A) light is applied to the cornea. The interaction between the riboflavin and the UV-A light triggers a photochemical reaction, specifically the creation of covalent bonds between collagen fibrils. These newly formed bonds effectively strengthen the cornea, increasing its rigidity and resistance to further deformation.
The procedure doesn’t reverse cornea changes that have already happened – it just keeps them from getting worse. Since it can help slow progression, it’s best to talk to your doctor sooner than later if you have keratoconus. By reinforcing the corneal structure, CXL can postpone or even eliminate the need for more invasive surgical interventions, such as corneal transplantation. This procedure is especially valuable in younger patients where keratoconus progression is often more rapid. The increased corneal strength achieved through CXL helps maintain the cornea's shape, ultimately preserving visual acuity and improving the patient's quality of life
How much does Crosslinking for Keratoconus cost?
The cost of corneal cross-linking (CXL) in the United States typically ranges from $2,500 to $4,000 per eye, though this can vary based on location, procedure type, and insurance coverage. While insurance coverage is increasing, it's crucial to verify your individual policy with your provider. For accurate pricing, consult with your ophthalmologist and contact your insurance company to understand potential out-of-pocket expenses.
Is crosslinkig for keratoconus covered by health insurance?
Coverage for corneal cross-linking (CXL) by health insurance in the United States varies, but FDA-approved procedures, like those using the iLink® system, have a higher likelihood of coverage, especially when deemed medically necessary. Insurance providers often cover the epithelium-off method, which is FDA-approved, while epithelium-on procedures are generally not covered. To determine specific coverage, it is essential to contact your insurance company directly, as policies differ, and documentation of progressive keratoconus may be required.
How does health insurance coverage for corneal cross-linking (CXL) work in the United States
Major national insurers like UnitedHealthcare and Aetna, along with regional Blue Cross Blue Shield plans, generally cover FDA-approved CXL procedures, particularly when progressive keratoconus is documented. However, coverage specifics vary greatly between plans, so it's essential to contact your insurance provider directly to verify your individual coverage.
Which corneal crosslinking method is covered?
Insurance coverage for corneal crosslinking (CXL) in the United States predominantly focuses on the FDA-approved epithelium-off method. This technique, which involves removing the corneal epithelium prior to applying riboflavin and UV-A light, is the standard for coverage, especially when utilizing the iLink® system developed by Glaukos Corporation (formerly Avedro, Inc.). Insurers generally prioritize this method because it has undergone rigorous FDA scrutiny and is supported by clinical evidence demonstrating its effectiveness in halting the progression of keratoconus.
Epithelium-on (transepithelial) CXL, a method that preserves the corneal epithelium, is typically not covered by insurance. This is largely due to its classification as experimental. Furthermore, insurance providers often require documentation of progressive keratoconus to establish medical necessity, reinforcing the emphasis on the FDA-approved epithelium-off technique for reimbursement.
What are the drugs and devices used in the FDA-approved corneal cross-linking?
The FDA-approved iLink® corneal cross-linking procedure for keratoconus employs Photrexa® and Photrexa® Viscous riboflavin solutions, which act as photosensitizers, and the KXL® System, a controlled UV-A light device. After epithelial removal, riboflavin is applied to saturate the corneal stroma. The KXL® System then delivers UV-A light, inducing a photochemical reaction that forms collagen cross-links, strengthening the cornea. This increased rigidity aims to halt keratoconus progression and potentially improve vision. This specific combination of Photrexa® solutions and the KXL® System is the only FDA-approved method for corneal cross-linking in the U.S.
What is the CPT code for corneal collagen crosslinking?
The CPT code for the corneal collagen crosslinking procedure itself is 0402T, which includes the removal of the corneal epithelium and intraoperative pachymetry when performed.
It's crucial to remember that insurance coverage and billing can be complex, and verification with the insurance provider is always recommended.
Does Photrexa® Viscous and Photrexa® have product specific J-code?
J-code J2787 has been issued by the Centers for Medicare and Medicaid Services for the use of Photrexa® Viscous (riboflavin 5’-phosphate in 20% dextran ophthalmic solution) and Photrexa® (riboflavin 5’-phosphate ophthalmic solution) formulas. This J-code (J2787) is used to bill for both Photrexa® and Photrexa® Viscous, as they are both riboflavin 5'-phosphate ophthalmic solutions, just with different viscosities.
Below is an updated list of insurance companies in United States that cover corneal collagen crosslinking (CXL) for progressive keratoconus:
| Payer Name | Payer Region | |
|---|---|---|
| Aetna | National | |
| AllWays Health Partners | MA | |
| AmeriHealth | DE, NJ, PA | |
| Anthem | National | |
| Arkansas Blue Cross Blue Shield | AR | |
| BCBS Health Advantage | AR | |
| BCBS of North Dakota | ND | |
| BCBS of Vermont | VT | |
| Blue Cross Blue Shield FEP | National | |
| Blue Cross Blue Shield of Alabama | AL | |
| Blue Cross Blue Shield of Arizona | AZ | |
| Blue Cross Blue Shield of Florida | FL | |
| Blue Cross Blue Shield of Georgia | GA | |
| Blue Cross Blue Shield of Illinois | IL | |
| Blue Cross Blue Shield of Kansas | KS | |
| Blue Cross Blue Shield of Kansas City | Kansas City, Northwestern MO, Johnson & Wyandotte Counties | |
| Blue Cross Blue Shield of Louisiana | LA | |
| Blue Cross Blue Shield of Massachusetts | MA | |
| Blue Cross Blue Shield of Michigan | MI | |
| Blue Cross Blue Shield of Minnesota | MN | |
| Blue Cross Blue Sheild of Mississippi | MS | |
| Blue Cross Blue Shield of Montana | MT | |
| Blue Cross Blue Shield of New Mexico | NM | |
| Blue Cross Blue Shield of North Carolina | NC | |
| Blue Cross Blue Shield of North Dakota | ND | |
| Blue Cross Blue Shield of Oklahoma | OK | |
| Blue Cross Blue Shield of Rhode Island | RI, CT, MA | |
| Blue Cross Blue Shield of South Carolina | SC | |
| Blue Cross Blue Shield of Tennessee | TN | |
| Blue Cross Blue Shield of Texas | TX | |
| Blue Cross and Blue Shield of Vermont | VT | |
| Blue Cross of Idaho | ID | |
| Blue Shield of California | CA | |
| BlueChoice Health Plan of South Carolina | SC | |
| Capital Blue Cross | Central PA | |
| Capital Health Plan | FL | |
| CareFirst Blue Cross Blue Shield | MD, DC, Northern VA | |
| Cigna Health | National | |
| ConnectiCare | CT | |
| Dean Health Plan | WI | |
| Emblem Health | NY | |
| Empire Blue Cross Blue Shield | NY | |
| Fallon Health | MA | |
| Geisinger Health | PA, DE, ME, NJ, WV | |
| Harvard Pilgrim | MA | |
| Hawaii Medical Service Association | HI | |
| Health Alliance Plan of Michigan | MI | |
| Health New England | MA | |
| HealthNet | CA, AZ | |
| HealthPartners Minnesota | MN, ND, SD, WI | |
| Highmark Blue Shield | DE, PA, WV | |
| Horizon Blue Cross of New Jersey | NJ | |
| Humana | National | |
| Independence Blue Cross | PA, NJ, DE, MD | |
| John Hopkins HealthCare | MD | |
| Kaiser Permanente | AZ, CA, CO, DC, GA, HI, MD, NV, TX, VA, WA | |
| Medica Health Plans | MN, WI, ND, SD | |
| Medical Mutual | OH | |
| Moda Health | OR | |
| Nebraska Blue | NE | |
| Premera Blue Cross | WA, OR, AK | |
| Presbyterian Health | NM, AZ, CO, TX | |
| Priority Health of Michigan | MI | |
| Providence Health Plan | OR, WA | |
| Public Employee Health Plan (PEHP) | UT | |
| Quartz - Unity Health | WI | |
| Regence Blue Cross Blue Shield | ID, OR, UT, WA | |
| Rocky Mountain Health Plans | CO, NE | |
| Scott & White Health Plan (SWHP) | TX | |
| Select Health | ID, UT | |
| Tricare | TRICARE Policy Manual: Rare Diseases, Eye And Ocular Adnexa, Available to all Tricare beneficiaries, including dependents. also see this comment. | |
| Tufts Health Plan | MA, RI | |
| United Healthcare | National | |
| Wellmark Blue Cross and Blue Shield | IA, SD | |
| This list is subject to change. It is not intended to be a directive, nor is it a suggestion about the likelihood of coverage or reimbursement. Please confirm with your individual carriers. | ||
Reimbursement questions and financial assistance
The iPath360 program by Glaukos is a service to help keratoconus patients with reimbursement questions, prescription assistance and the possibility of financial assistance for eligible patients.
Call the iPath360 hotline 844-528-3311 for questions about coding, billing, claims submissions or payer coverage for corneal cross-linking with Photrexa® Viscous and Photrexa® with the KXL® System.
Visit iPath360's website and Avedro's website to learn more about insurance coverage and find resources and cornea specialist who perform corneal crosslinking.