BlueCross and BlueShield of Montana Medical Policy/Codes
Corneal Topography, Computer Assisted Photokeratoscopy
Chapter: Vision
Current Effective Date: February 01, 2014
Original Effective Date: August 05, 1999
Publish Date: January 15, 2014
Revised Dates: June 25, 2002; March 1, 2005, November 7, 2011; August 31, 2012; October 24, 2013; January 15, 2014
Description

Computer-assisted topography/photokeratoscopy provides a quantitative measure of corneal curvature. Measurement of corneal topography is being evaluated for the diagnosis and follow-up of corneal disorders such as keratoconus, difficult contact lens fits, and pre- and postoperative assessment of the cornea, most commonly after refractive surgery.

Corneal topography describes measurements of the curvature of the cornea. An evaluation of corneal topography is necessary for the accurate diagnosis and follow-up of certain corneal disorders, such as keratoconus, difficult contact lens fits, and pre- and postoperative assessment of the cornea, most commonly after refractive surgery. Various techniques and instruments are available to measure corneal topography:

  • The keratometer (also referred to as an ophthalmometer), the most commonly used instrument, projects an illuminated image onto a central area in the cornea. By measuring the distance between a pair of reflected points in both of the cornea’s two principal meridians, the keratometer can estimate the radius of curvature of two meridians. The fact that the keratometer can only estimate the corneal curvature over a small percentage of its surface and that estimates are based on the frequently incorrect assumption that the cornea is spherical, are limitations of this technique.
  • The keratoscope is an instrument that reflects a series of concentric circular rings off the anterior corneal surface. Visual inspection of the shape and spacing of the concentric rings provides a qualitative assessment of topography. A photokeratoscope is a keratoscope equipped with a camera that can provide a permanent record of the corneal topography.
  • Computer-assisted photokeratoscopy is an alternative to keratometry or keratoscopy in measuring corneal curvature. This technique uses sophisticated image analysis programs to provide quantitative corneal topographic data. Early computer-based programs were combined with keratoscopy to create graphic displays and high-resolution color-coded maps of the corneal surface. Newer technologies measure both curvature and shape, enabling quantitative assessment of corneal depth, elevation, and power.

Regulatory Status

A number of devices have received clearance for marketing through the U.S. Food and Drug Administration (FDA) 510(k) mechanism. The Orbscan® (manufactured by Orbtek and distributed by Bausch and Lomb) received FDA clearance in 1999. The second generation Orbscan II is a hybrid system that uses both projective (slit scanning) and reflective (Placido) methods. The Pentacam® (Oculus) is one of a number of rotating Scheimpflug imaging systems produced in Germany.

Policy

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions.  Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there is any exclusion or other benefit limitations applicable to this service or supply.  If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coverage

Computerized corneal topography is considered not medically necessary to detect or monitor diseases of the cornea.     

Rationale

This policy was created in 1999 and updated periodically using the MEDLINE database. The most recent literature update was performed through March 13, 2013.

Detection and Monitoring Diseases of the Cornea

Assessing corneal topography has been done for many years and is a part of the standard ophthalmologic examination of some patients. (1, 2) However, corneal topography can be evaluated and determined in multiple ways. Computer-assisted corneal topography has been used for early identification and quantitative documentation of the progression of keratoconic corneas, and evidence is sufficient to indicate that computer-assisted topographical mapping can detect and monitor disease. However, the question that is pertinent to this policy is whether quantitative measurement results in an intervention change that improves health outcomes.

Contact Lens Fitting in Patients with Keratoconus

A 2010 study was identified on computer-assisted corneal topography for the design of gas-permeable contact lens in 30 patients with keratoconus, who were recruited for the study in 2005-2006. (3) The report indicates that the subjects were consecutive, although patients whose topographical plots could not be used were excluded (number not described). The fit of the new lens was compared with the fit of the patient’s habitual lens (randomized order on the same day). Clinical evaluation showed a good fit (no or minor modification needed) for more than 90% of the computer-designed lens. However, progression of keratoconus causes a bias favoring the most recently fitted lens, confounding the comparison between the new computer-designed lens and the patient’s habitual lens. This study has substantial limitations in both design and reporting.

Corneal Astigmatism Measurements for Toric Intraocular Lens Implantation

In 2012, Lee et al. reported a prospective comparative study of 6 methods of measuring corneal astigmatism for the purpose of toric intraocular lens implantation. (4) Astigmatism was evaluated in 257 eyes (141 patients) using manual keratometry, autokeratometry, partial coherence interferometry (IOLMaster®), ray-tracing aberrometry (iTrace™), scanning-slit topography (Orbscan®), and Scheimpflug imaging (Pentacam®). All measurements were masked to the results for the other instruments. The study found no significant difference between the different instruments, indicating no advantage to computerized corneal topography compared to manual keratometry.

Summary

With the exception of refractive surgery, a service not generally covered as a health insurance benefit, no studies have shown clinical benefit (e.g., a change in treatment decisions) from a quantitative rather than qualitative evaluation of corneal topography. Therefore, due to the additional cost of this procedure and a lack of scientific evidence from appropriately constructed clinical trials that confirm improved health outcomes, quantitative evaluation of corneal topography, including evaluation with computer assistance, is considered not medically necessary.

Practice Guidelines and Position Statements

A 1999 American Academy of Ophthalmology (AAO) assessment indicates that computer-assisted corneal topography evolved from the need to measure corneal curvature and topography more comprehensively and accurately than keratometry and that corneal topography is used primarily for refractive surgery. (5) The AAO indicates several other potential uses: 1) evaluate and manage patients following penetrating keratoplasty, 2) plan astigmatic surgery, 3) evaluate patients with unexplained visual loss and document visual complications, and 4) fit contact lenses. However, the AAO assessment noted that data are lacking to support the use of objective measurements, as opposed to subjective determinants (subjective refraction) of astigmatism.

Coding

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps. 

ICD-9 Codes

Not medically necessary for all diagnoses.

ICD-10 Codes

Not medically necessary for all diagnoses.

Procedural Codes: 92025
References
  1. Morrow GL, Stein RM. Evaluation of corneal topography: past, present and future trends. Can J Ophthalmol 1992; 27(5):213–25.
  2. Wilson SE, Klyce SD. Advances in the analysis of corneal topography. Surv Ophthalmol 1991; 35(4-Jan):269–77.
  3. Bhatoa NS, Hau S, Ehrlich DP. A comparison of a topography-based rigid gas permeable contact lens design with a conventionally fitted lens in patients with keratoconus. Cont Lens Anterior Eye 2010; 33(3):128-35.
  4. Lee H, Chung JL, Kim EK et al. Univariate and bivariate polar value analysis of corneal astigmatism measurements obtained with 6 instruments. J Cataract Refract Surg 2012; 38(9):1608-15.
  5. Ophthalmic Technology Assessment Committee Cornea Panel American Academy of Ophthalmology. Corneal topography. Ophthalmology 1999; 106(8-Jan):1628-38.
  6. Corneal Topography/Computer-Assisted Corneal Topography/Photokeratoscopy. Chicago, Illinois:  Blue Cross Blue Shield Association Medical Policy Reference Manual (2013 April) Other 9.03.05.
History
November 2011  Policy revised: Policy statement change from medically necessary criteria to strictly not medically necessary for computer assisted corneal topography/photoderatoscopy. Name change from Corneal Topagraphy to Corneal Topography/Computer-Assisted Corneal Topography/Photokeratoscopy
August 2012 Policy updated with literature review through February 2012; policy statement unchanged
November 2013 Policy formatting and language revised.  Policy statement unchanged.  Title changed from "Corneal Topography/Computer-Assisted Corneal Topography/Photokeratoscopy" to "Corneal Topography, Computer Assisted Photokeratoscopy".  Added category III code 0181T and removed codes 76514 and S0820.
February 2014 Document updated with literature review. Coverage unchanged.
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Corneal Topography, Computer Assisted Photokeratoscopy