POLICY . . . . . . . . PG-0174
EFFECTIVE . . . . . 10/01/08
LAST REVIEW . . . 01/12/16
MEDICAL POLICY
Intrastromal Corneal Ring Segments
(INTACS)
GUIDELINES
This policy does not certify benefits or authorization of benefits, which is designated by each individual policyholder
contract. Paramount applies coding edits to all medical claims through coding logic software to evaluate the
accuracy and adherence to accepted national standards. This guideline is solely for explaining correct procedure
reporting and does not imply coverage and reimbursement.
DESCRIPTION
The intrastromal corneal ring segment (INTACS) procedure involves inserting a flexible ring beneath the surface of
the cornea to elevate the edge the cornea. This effectively flattens the front of the eye, decreasing
nearsightedness. Different size rings are used to correct different amounts of nearsightedness. It can also be used
to correct disorders such as keratoconus in which there is bulging of the cornea, or other forms of cornea ectasia.
The procedure is usually performed in the ambulatory setting under local anesthesia by an ophthalmologist.
POLICY
INTACS (65785) requires prior authorization for HMO, PPO, Individual Marketplace, Elite & Advantage.
HMO, PPO, Individual Marketplace, Elite, Advantage
Coverage for services for or related to routine refraction and the surgical treatment of refractive errors is specifically
excluded under many benefit plans. Please refer to the applicable benefit plan document to determine benefit
availability, and the terms and conditions of coverage.
If coverage is available for services for or related to routine refraction and the surgical treatment of refractive errors,
the following conditions of coverage apply.
INTACS is considered medically necessary in patients with keratoconus who meet all of the following criteria:
1. Progressive deterioration in vision, such that patients can no longer achieve adequate functional vision on
a daily basis with their contact lenses or spectacles; and
2. 21 years of age or older; and
3. Presence of mostly clear central cornea; and
4. Central corneal thickness of 450 microns or greater; and
5. Who have corneal transplantation as the only remaining option to improve their functional vision.
Treatment for post-LASIK ectasia is not a FDA-approved indication for INTACS. This service will be denied.
This surgical service is often reported with a prosthetic implant (L8610). There will be no separate reimbursement
for this item, as it is considered a surgical supply. The implant supply will be denied when reported by the facility.
This is a covered service for these product lines for both physicians and facilities. It is usually performed in the
ASC facility setting as an outpatient service. If this procedure is reported without one of the medically supported
diagnosis, the service will be denied.
This service will only be allowed with the following medical diagnoses:
ICD-9-CM CODES - EFFECTIVE prior to 10/01/2015
367.0
Hypermetropia
367.1
Myopia
367.20-367.22
Astigmatism
371.48
Peripheral degenerations of cornea
371.60-371.62
Keratoconus
ICD-10-CM CODES - EFFECTIVE after 10/01/2015
H18.461- H18.469
Peripheral corneal degeneration
H18.601- H18.629
Keratoconus
H52.00- H52.03
Hypermetropia
H52.10- H52.13
H52.201- H52.229
Myopia
Astigmatism
CODING/BILLING INFORMATION
The appearance of a code in this section does not necessarily indicate coverage. Codes that are covered may have selection criteria
that must be met. Payment for supplies may be included in payment for other services rendered.
CPT CODES
65785 Implantation of intrastromal corneal ring segments (Effective 1/1/16 new code)
0099T Implantation of intrastromal corneal ring segments (Effective 12/31/15 deleted code)
REVISION HISTORY EXPLANATION
04/01/10: Updated
01/01/11: No changes
01/14/14: ICD-10 Codes added from ICD-9 conversion. Policy reviewed and updated to reflect most current clinical
evidence. Approved by Medical Policy Steering Committee as revised.
01/12/16: Added effective 1/1/16 new code 65785. ICD-9 codes 367.0, 367.1, 367.20-367.22, 371.48, 371.60371.62 or ICD-10 codes H18.461- H18.469, H18.601- H18.629, H52.00- H52.03, H52.10- H52.13, H52.201H52.229 must be billed with procedure code 65785. Prior authorization is now required for PPO for INTACS. Policy
reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee.
REFERENCES/RESOURCES
Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services
Ohio Department of Medicaid http://jfs.ohio.gov/
American Medical Association, Current Procedural Terminology (CPT®) and associated publications and services
Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS Release
and Code Sets
Industry Standard Review
Hayes, Inc.