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«PacifiCare’s medical management guidelines represent the recommendation of the PacifiCare Medical Management Guideline (MMG) committee. They are ...»

-- [ Page 107 ] --

American Academy of Ophthalmology (AAO). Web site. Preferred Practice Pattern. Refractive

Errors and Refractive Surgery. September 2007. Available at:

http://one.aao.org/asset.axd?id=b5e06307-8a97-4675-8174-367ed4eb355b. Accessed March 2009.

American Society of Cataract and Refractive Surgery (ASCRS) Web site. LASIK patient screening

guidelines. 2003. Available at:

http://www.lasikinstitute.org/LASIK_Patient_Screening_Guidelines.html. Accessed March 2009.

Autrata R, Rehurek J. Laser-assisted subepithelial keratectomy and photorefractive keratectomy for the correction of hyperopia. Results of a 2-year follow-up. J Cataract Refract Surg.

2003b;29(11):2105-2114.

Autrata R, Rehurek J. Laser-assisted subepithelial keratectomy for myopia: two-year follow-up. J Cataract Refract Surg. 2003a;29(4):661-668.

Excimer Laser- Commercial Medical Management Guideline Behrens A, Seitz B, Langenbucher A, et al. Lens opacities after nonmechanical versus mechanical corneal trephination for keratoplasty in keratoconus. J Cataract Refract Surg. 2000;26(11):1605Buzard K, Febbraro JL, Fundingsland BR.Laser in situ keratomileusis for the correction of residual ametropia after penetrating keratoplasty. J Cataract Refract Surg. 2004 May;30(5):1006-13.

Chiang RK, Park AJ, Rapuano CJ, Cohen EJ. Bilateral keratoconus after LASIK in a keratoconus patient. Eye Contact Lens. 2003 Apr;29(2):90-2.

Das S, Langenbucher A, Pogorelov P, Link B, Seitz B. Long-term outcome of excimer laser phototherapeutic keratectomy for treatment of Salzmann's nodular degeneration. J Cataract Refract Surg. 2005a Jul;31(7):1386-91.

Das S, Langenbucher A, Seitz B. Delayed healing of corneal epithelium after phototherapeutic keratectomy for lattice dystrophy. Cornea. 2005c Apr;24(3):283-7.

Das S, Langenbucher A, Seitz B. Excimer laser phototherapeutic keratectomy for granular and lattice corneal dystrophy: a comparative study. J Refract Surg. 2005b Nov-Dec;21(6):727-31.

Dausch D, Landesz M, Klein R, Schroder E. Phototherapeutic keratectomy in recurrent corneal epithelial erosion. Refract Corneal Surg. 1993;9(6):419-424.

Dausch D, Schroder E, Dausch S. Toopography-controlled excimer laser photorefractive keratectomy. J Refract Surg;16(1):13-22.

Donnenfeld ED, Kornstein HS, Amin A, et al. Laser in situ keratomileusis for correction of myopia and astigmatism after penetrating keratoplasty. Ophthalmology. 1999 Oct;106(10):1966-74;

discussion 1974-5.

ECRI Institute. Custom Hotline Response. LASIK Surgery and Keratoconus. July 2005. Archived Report.

El-Maghraby A, Salah T, Waring GO 3rd, et al. Randomized bilateral comparison of excimer laser in situ keratomileusis and photorefractive keratectomy for 2.50 to 8.00 diopters of myopia.

Ophthalmology. 1999;106(3):447-457.

Elsahn AF, Rapuano CJ, Antunes VA, Abdalla YF, Cohen EJ. Excimer laser phototherapeutic keratectomy for keratoconus nodules. Cornea. 2009 Feb;28(2):144-7.

Hafner A, Seitz B, Langenbucher A, Naumann GO. [Phototherapeutic keratectomy (o-PTK) with 193 Excimer Laser- Commercial Medical Management Guideline nm excimer laser for superficial corneal scars. Prospective long-term results of 31 consecutive operations] Ophthalmologe. 2004 Feb;101(2):135-9.

Hardten DR, Chittcharus A, Lindstrom RL. Long term analysis of LASIK for the correction of refractive errors after penetrating keratoplasty. Cornea. 2004 Jul;23(5):479-89.

Hayes, Inc. Hayes Directory. Laser In Situ Keratomileusis. September 2002. Updated search October

2007. Archived.

Horackova M, Loukotova V, Hlinomazova Z, Vlkova E. [Long-term results of the postoperative ametropia correction after perforating keratoplasty using the LASIK method][Article in Czech] Cesk Slov Oftalmol. 2008 Jan;64(1):3-10.

Jin GJ, Merkley KH, Lyle WA. Laser in situ keratomileusis for primary and secondary mixed astigmatism. Am J Ophthalmic. 2005 Jun;139(6):1019-27.

Kato N, Toda I, Hori-Komai Y, Sakai C, Tsubota K. Five-year outcome of LASIK for myopia.

Ophthalmology. 2008 May;115(5):839-844.e2.

Knorz MC, Jendritza B. Topographically-guided laser in situ keratomileusis to treat corneal irregularities. Ophthalmology. 2000;107(6):1138-1143.

Kuchle M, Nguyen NX, Seitz B, et al. Blood-aqueous barrier after mechanical or nonmechanical excimer laser trephination in penetrating keratoplasty. Am J Ophthalmol. 1998;125(2):177-181.

Kymionis GD, Panagopoulou SI, Aslanides IM, et al., Topographically supported customized ablation for the management of decentered laser in situ keratomileusis. Am J Ophthalmol.

2004;137(5):806-811.

La Tegola MG, Alessio G, Sborgia C. Topographic customized photorefractive keratectomy for regular and irregular astigmatism after penetrating keratoplasty using the LIGI CIPTA/LaserSight platform. J Refract Surg. 2007 Sep;23(7):681-93.

Langenbucher A, Seitz B, Kus MM, et al. Graft decentration in penetrating keratoplasty:

nonmechanical trephination with the excimer laser (193 nm) versus the motor trephine. Ophthalmic Surg Lasers. 1998;29(2):106-113.

Li Y, Li JH, Zhou F. LASEK for the correction of residual myopia and astigmatism after LASIK.

[Article in Chinese] Zhonghua Yan Ke Za Zhi. 2005 Nov;41(11):981-5.

Lima G da S, Moreira H, Wahab SA.Laser in situ keratomileusis to correct myopia, hypermetropia Excimer Laser- Commercial Medical Management Guideline and astigmatism after penetrating keratoplasty for keratoconus: a series of 27 cases. Can J Ophthalmol. 2001 Dec;36(7):391-6; discussion 396-7.





Lin DY, Manche EE. Custom-contoured ablation pattern method for the treatment of decentered laser ablation. J Cataract Refract Surg. 2004;30(8):1675-1684.

Lin PY, Wu CC, Lee SM. Combined phototherapeutic keratectomy and therapeutic contact lens for recurrent erosions in bullous keratopathy. Br J Ophthalmol. 2001;85(8):908-911.

Lindstrom RL, Hardten DR, Houtman DM, et al. Six-month results of hyperopic and astigmatic LASIK in eyes with primary and secondary hyperopia. Trans Am Ophthalmol Soc. 1999;97:241-55;

discussion 255-60.

Manche EE, Carr JD, Haw WW, Hersh PS. Excimer laser refractive surgery. West J Med.

1998;169(1):30-38.

National Institute for Health and Clinical Excellence. Guidance for photorefractive (laser) surgery for

the correction of refractive errors. March 2006. Available at:

http://guidance.nice.org.uk/IPG164/guidance/pdf/English. Accessed March 2009.

Norouzi H, Rahmati-Kamel M. Laser in situ keratomileusis for correction of induced astigmatism from cataract surgery. J Refract Surg. 2003 Jul-Aug;19(4):416-24.

Ohman L, Fagerholm P. The influence of excimer laser ablation on recurrent corneal erosions: a prospective randomized study. Cornea. 1998;17(4):349-352.

Pogorelov P, Langenbucher A, Kruse F, Seitz B. Long-term results of phototherapeutic keratectomy for corneal map-dot-fingerprint dystrophy (Cogan-Guerry). Cornea. 2006 Aug;25(7):774-7.

Seitz B, Langenbucher A, Kus MM, et al. Nonmechanical corneal trephination with the excimer laser improves outcome after penetrating keratoplasty. Ophthalmology. 1999;106(6):1156-1165.

Seitz B, Langenbucher A, Nguyen NX, et al. Graft endothelium and thickness after penetrating keratoplasty, comparing mechanical and excimer laser trephination: a prospective randomised study.

Graefes Arch Clin Exp Ophthalmol. 2001;239(1):12-17.

Seitz B, Langenbucher A, Nguyen NX, et al. Long-term follow-up of intraocular pressure after penetrating keratoplasty for keratoconus and Fuchs' dystrophy: comparison of mechanical and Excimer laser trephination. Cornea. 2002;21(4):368-373.

Stewart OG, Morrell AJ. Management of band keratopathy with excimer phototherapeutic Excimer Laser- Commercial Medical Management Guideline keratectomy: visual, refractive, and symptomatic outcome. Eye. 2003;17(2):233-237.

Thomann U, Meier-Gibbons F, Schipper I. Phototherapeutic keratectomy for bullous keratopathy. Br J Ophthalmol. 1995;79(4):335-338.

Varley GA, Huang D, Rapuano CJ, Schallhorn S, Boxer Wachler BS, Sugar A; Ophthalmic Technology Assessment Committee Refractive Surgery Panel, Ameican Academy of Ophthalmology. LASIK for hyperopia, hyperopic astigmatism, and mixed astigmatism: a report by the American Academy of Ophthalmology. Ophthalmology. 2004 Aug;111(8):1604-17.

Wiesinger-Jendritza B, Knorz MC, Hugger P, Liermann A. Laser in situ keratomileusis assisted by corneal topography. J Cataract Refract Surg. 1998;24(2):166-174.

Wu l, Zhou X, Ouyang Z, Weng C, Chu R. Topography-guided treatment of decentered laser ablation using LaserSight's eximer laser. Eur J Ophthalmol. 2008;Sept-Oct;18(5):708-15.

Xie L, Gao H, Shi W. Long-term outcomes of photorefractive keratectomy in eyes with previous epikeratophakia for keratoconus. Cornea 2007 Dec;26(10):1200-4.

History/Updates Policy revision with changes to the coverage rationale. CMS information updated.

7/1/2009 Deleted CPT codes 65400, 65771, 65772, and 65775 and ICD-9 Procedure codes 11.49, 11.75, and 11.79 from the coding section. Added CPT code 65450 to the coding section. Deleted ICD-9 Diagnosis codes 370.00, 371.40, and 371.42 from the coding section. Added ICD-9 diagnosis codes 371.51, 371.52, 371.55, 371.71, 371.72, 371.73, and 743.42 to the coding section. Policy 2008T0199F archived.

Policy update. CMS information updated. Policy 2007T0199E archived.

12/1/2008 Updated coding section.

10/31/2008 Policy revision with changes to coverage rationale (added photorefractive keratectomy 11/15/2007 (PRK) for treatment of refractive eye errors and added excimer laser phototherapeutic keratectomy (PTK) for the treatment of corneal disorders). CMS information updated.

Added CPT codes 65772, 65775, and 66999 to the coding section. Added ICD-9 diagnostic and procedure codes to the coding section. Policy 2004T0199D archived.

Policy revision with new indications added to the coverage rational.

11/18/2004 CPT codes 65400, 65771 and HCPCS codes S0800, S0810 and S0812 added to 8/31/2004 Coding Section per direction from the Reimbursement Medical Policy Operations Excimer Laser- Commercial Medical Management Guideline

–  –  –

Contact Information For questions regarding this policy, send an email to the Medical Technology Interpretation Service at medical_drug_interpretation@uhc.com with the word "Medical" in the subject line.

Coding The Current Procedural Terminology (CPT) codes and HCPCS codes listed in this policy are for reference purposes only. Listing of a service code in this policy does not imply that the service described by this code is a covered or non-covered health service. Coverage is determined by the benefit document.

–  –  –

Excimer Laser- Commercial Medical Management Guideline 370.07 Mooren's ulcer 371.00 Unspecified corneal opacity 371.01 Minor opacity of cornea 371.02 Peripheral opacity of cornea 371.03 Central opacity of cornea 371.23 Bullous keratopathy 371.43 Band-shaped keratopathy 371.46 Nodular degeneration of cornea 371.51 Juvenile epithelial corneal dystrophy 371.52 Other anterior corneal dystrophies 371.55 Macular corneal dystrophy 371.57 Endothelial corneal dystrophy 371.60 Unspecified keratoconus 371.61 Keratoconus, stable condition 371.62 Keratoconus, acute hydrops 371.70 Unspecified corneal deformity 371.71 Corneal ectasia 371.72 Descemetocele 371.73 Corneal staphyloma 743.41 Congenital anomaly of corneal size and shape 743.42 Congenital corneal opacity, interfering with vision CPT Procedure Code 65450 Destruction of lesion of cornea by cryotherapy, photocoagulation or thermocauterization This information is being distributed to you for personal reference. The information belongs to UnitedHealthcare and unauthorized copying, use and distribution are prohibited. This information is intended to serve only as a general reference resource regarding our Medical Policies and is not

Excimer Laser- Commercial Medical Management Guideline

intended to address every aspect of a clinical situation. Physicians and patients should not rely on these Medical Policies in making health care decisions. Physicians and patients must exercise their independent clinical discretion and judgment in determining care. The enrollee's specific benefit documents supercede these policies and are used to make coverage determinations. These Medical Policies are believed to be current as of the date noted.

Confidential and Proprietary, © UnitedHealthcare, Inc. 2009 Excimer Laser- Commercial Medical Management Guideline TITLE: Extracorporeal Shock Wave Therapy (ESWT) for Orthopedic Indications Authorized By: Medical Management Guideline Committee

Adoption Date: 10/14/09 Revision Date:

Disclaimer This medical management guideline represents the recommendation of the PacifiCare Medical Management Guideline (MMG) committee. It is based on the MMG committee's review of the available evidence as of the date of this medical management guideline.

This medical management guideline contains clinical practice and utilization criteria to assist professionals in PacifiCare’s medical management practice when making medical necessity determinations prior to, subsequent to, or concurrent with the provisions of health care services. This medical management guideline is intended to support consistent, appropriate medical necessity determinations, but it does not replace an individualized case-by-case review and medical necessity determination for each PacifiCare member.

Member benefit coverage and limitations may vary based on the member’s benefit plan.

This information is being distributed to you for personal reference. The information belongs to UnitedHealthcare and unauthorized copying, use and distribution are prohibited. This information is intended to serve only as a general reference resource regarding our Medical Policies and is not intended to address every aspect of a clinical situation. Physicians and patients should not rely on these Medical Policies in making health care decisions. Physicians and patients must exercise their independent clinical discretion and judgment in determining care. The enrollee's specific benefit documents supercede these policies and are used to make coverage determinations. These Medical Policies are believed to be current as of the date noted.

–  –  –



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