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Computerized Corneal Topography

POLICY HISTORY

Last Review: 03/04/2022

Effective: 05/06/1996

Next Review: 01/26/2023

Review History

Definitions

Number: 0130

POLICY *Please see amendment forPennsylvaniaMedicaid at theend of this CPB.

I. Aetnaconsiderscomputerizedcornealtopographymedically

necessary for any of the following conditions:

Central corneal ulcer; or

Corneal dystrophy, bullous keratopathy and complications of

transplanted cornea; or

Diagnosing and monitoring disease progression in

keratoconus or Terrien's marginal degeneration; or

Difficult fitting of contact lens (see CPB 0126 - Contact Lenses

and Eyeglasses (0126.html)) *; or

Evaluating corneal ectasia; or

Post-traumatic corneal scarring; or

Pre- and post-penetrating keratoplasty and post kerato-

refractive surgery for irregular astigmatism (subject to medical

necessity criteria for these procedures - see CPB 0023 - Corneal

Remodeling (../1_99/0023.html)); or

Pterygium or pseudo pterygium.

* Generally, 1 testing for each eye is sufficient for fitting, unless

there is some reason for repeat testing conducted in the medical

record, such as a change in the member's condition from the prior

examination. Repeat testing to monitor disease progression in

keratoconus or Terrien's marginal degeneration may be necessary

over time.


II. Note: Aetna does not cover corneal topography if it is

performed pre- or post-operatively in relation to a non-covered

procedure (i.e., refractive eye surgery). Most Aetna benefit

plans exclude coverage of refractive surgery. Please check

benefit plan descriptions for details.

III. Aetna considers corneal topography experimental and

investigational if it is performed as part of pre-operative

assessment of members with cataracts (see CPB 0508 - Cataract

Removal Surgery (../500_599/0508.html)).

IV. Aetna considers corneal topography experimental and

investigational for the management of members with the following

indications (not an all-inclusive list) because corneal topography

has not been shown to alter the clinical management of these

conditions such that clinical outcomes are improved:

Acanthomoeba keratitis

Accommodative disorders

Band keratopathy

Diplopia

Epithelial ingrowth following laser in situ keratomileusis (LASIK)

Interstitial keratitis

Kerato-conjunctivitis sicca

Lattice degeneration of retina

Lens subluxation ( e.g., in M arfan s yndrome)

Limbal dermoids

Microphthalmia

Nodular degeneration of the cornea (e.g., Salzmann's corneal

degeneration)

Ocular graft-versus-host disease

Ocular surface squamous neoplasia

Open-angle glaucoma

Post-herpes simplex virus scarring of cornea

Refractive errors

Superficial punctate k eratopathy.


BACKGROUND Computerized corneal topography (also known as computer assisted

corneal topography, computer assisted keratography, or

videokeratography) is a computer- assisted diagnostic technique in which

a special instrument projects a series of light rings on the cornea, creating

a color-coded map of the corneal surface as well as a cross-section

profile. This test is used for the detection of subtle corneal surface

irregularities and astigmatism as an alternative to manual keratometry.

The American Academy of Ophthalmology’s guidelines on “Primary open-

angle glaucoma” (AAO, 2010) mentioned no role for corneal topography

in the management of patients with open-angle glaucoma.

Choi and Kim (2012) examined the longitudinal changes in corneal

topographic indices over time in patients with mild keratoconus (KC) and

determined predictive factors for the increase in corneal curvature. These

investigators retrospectively reviewed the data of 94 eyes of patients with

mild KC who had undergone computerized video-keratography (Orbscan

IIz; Bausch & Lomb Surgical, Rochester, NY) at least twice at an interval

of greater than or equal to 1 year. Patients with an increase of greater

than or equal to 1.50 diopters (D) in the central keratometry (K) were

placed in the progression group, and the others were placed in the non-

progression group. In each group, the quantitative topographic

parameters were compared and tested as predictive factors for KC

progression. Additionally, corneal astigmatic changes were evaluated by

means of vector analysis. In total, 94 eyes of 85 patients were included --

25 of 94 (26.5 %) eyes showed progression of the central K greater than

or equal to 1.50 D; progression took 3.5 years on average. Median time

to progression by Kaplan-Meier analysis was 12 years. Significant

predictors for KC progression were as follows: highest point on the

anterior elevation from the anterior best-fit sphere (BFS), greater than or

equal to 0.04 mm; irregularity index at 3 mm, greater than or equal to 6.5

D; irregularity index at 5 mm, greater than or equal to 6.0 D; thinnest

pachymetry, less than 350 μm at baseline examination; yearly change

rate of anterior BFS, greater than or equal to 0.1 D/year; central K,

greater than or equal to 0.1 D/year; simulated K in maximum, greater than

or equal to 0.15 D/year; simulated K in minimum, greater than or equal to

0.2 D/year; and anterior chamber depth, greater than or equal to 0.0

mm/year. The dominant with-the-rule pattern of astigmatism at the

baseline examination was changed to an oblique pattern of astigmatism


at the last examination. The authors concluded that mild KC tended to be

progressive in approximately 25 % of patients, and progression lasted 3.5

years on average. They stated that longitudinal changes in the corneal

topography quantitative indices can be used as predictors of KC

progression.

Follow-Up Evaluation of Keratoconus

An UpToDate review on “Keratoconus” (Wayman, 2015) states that

“Corneal topography -- The introduction of corneal topography has helped

in the identification of subtle presentations, which can lead to an earlier

diagnosis. Major topographic patterns found in keratoconus include

asymmetric bowtie, with or without inferior steepening, and skewed radial

axes. However, once the diagnosis is made, serially corneal topography

is of little value in following patients”.

Microphthalmia

Hu and colleagues (2015) determined the typical corneal changes in pure

microphthalmia using a corneal topography system and identified

characteristics that may assist in early diagnosis. Patients with pure

microphthalmia and healthy control subjects underwent corneal

topography analysis to determine degree of corneal astigmatism (mean

A), simulation of corneal astigmatism (sim A), mean keratometry (mean

K), simulated keratometry (sim K), irregularities in the 3 - and 5-mm zone,

and mean thickness of 9 distinct corneal regions. Patients with pure

microphthalmia (n = 12) had significantly higher mean K, sim K, mean A,

sim A, 3.0 mm irregularity and 5.0 mm irregularity, and exhibited

significantly more false keratoconus than controls (n = 12). There was a

significant between-group difference in the morphology of the anterior

corneal surface and the central curvature of the cornea. The authors

concluded that changes in corneal morphology observed in this study

could be useful in borderline situations to confirm the diagnosis of pure

microphthalmia. These preliminary findings need to be validated by

well- designed studies.

Other Experimental Indications

In a retrospective, clinic-based, case-control study, de Paiva et al (2003)

determined the correlation between the regularity indices of the Tomey

TMS-2N computerized videokeratoscopy (CVK) instrument (Tomey,

Waltham, MA) with conventional measures of dry eye symptoms and


disease. A total of 16 eyes of 16 asymptomatic normal subjects and 74

eyes of 74 patients with reports of ocular irritation were included in this

study. Corneal surface regularity and potential visual acuity indices

(PVAI) of the Tomey TMS-2N CVK instrument were evaluated in patients

with ocular irritation symptoms and in normal subjects. The surface

regularity index (SRI), surface asymmetry index (SAI), PVAI, and irregular

astigmatism index (IAI) of the Tomey TMS-2N were compared between

normal and dry-eye patients. Severity of dry-eye symptoms was

assessed with a validated questionnaire. Schirmer 1 test (without

anesthesia), biomicroscopic meibomian gland evaluation with a

composite severity score (MGD score), fluorescein tear break-up time

(TBUT), and corneal fluorescein staining were performed. The

correlations between CVK indices of the Tomey TMS-2N and the

symptom severity score, Schirmer 1 test, MGD score, TBUT, and corneal

fluorescein staining score were studied. Dry-eye patients had greater

mean symptom severity scores, lower Schirmer 1 test scores, greater

MGD scores, more rapid TBUT, and greater total corneal fluorescein

staining scores (p < 0.001 for all parameters). The SRI, SAI, and IAI

were all significantly greater in dry-eye patients than normal subjects.

These were 0.46 +/- 0.36 (normal) versus 1.09 +/- 0.76 (dry) for the SRI

(p= 0.0017), 0.30 +/- 0.15 (normal) versus 0.90 +/- 1.09 (dry) for the SAI

(p = 0.0321), and 0.42 +/- 0.28 (normal) versus 0.56 +/- 0.24 (dry) for the

IAI (p = 0.0321). The PVAI was significantly lower in the dry-eye patients

(0.89 +/- 0.13) than normal eyes (0.68 +/- 0.23; p = 0.0008). The SRI,

SAI, and IAI were pos itively correlated with total and central corneal

fluorescein staining scores (p < 0.00001 for all indices). An SRI greater

than or equal to 0.80), SAI (greater than or equal to 0.50), and IAI

(greater than or equal to 0.50) had sensitivities in predicting total corneal

fluorescein staining (score greater than or equal to 3) of 89 %, 69 %, and

82 %, respectively. The specificity of these indices was 80 %, 78 %, and

82 %, respectively. In all 90 eyes, the mean SRI was greater in subjects

older than 50 years (p = 0.012) compared with younger patients, whereas

no age effect was noted in the dry-eye patients. The SRI and PVAI

showed better correlation with symptoms of blurred vision than the best-

corrected visual acuity (BCVA). The authors concluded that patients with

ocular irritation had an irregular corneal surface that may contribute to

their irritation and visual symptoms. Because of their high sensitivity and

specificity, the regularity indices of the Tomey TMS-2N have the potential

to be used as objective diagnostic indices for dry eye, as well as a means

to evaluate the severity of this disease.


The American Academy of Ophthalmology Cornea/External Disease

Panel’s Preferred Practice Pattern on “Dry Eye Syndrome” (AAO, 2013)

had no recommendation for computerized corneal topography.

The AAO’s guideline on “Herpes simplex virus keratitis” (White and

Chodosh, 2014) does not include a recommendation for corneal

topography.

Furthermore, UpToDate reviews on “Retinal detachment” (Arroyo, 2018)

and “Diagnosis and classification of Sjogren's syndrome” (Baer, 2018) do

not mention corneal topography as a management tool.

Evaluation of Corneal Ectasia

The AAO Preferred Practice Pattern Cornea and External Disease

Panel’s “Corneal Ectasia Preferred Practice Pattern” (Garcia-Ferrer et al,

2019) states that “Corneal ectasia is progressive corneal steepening and

thinning. Types of corneal ectasia include keratoconus, pellucid marginal

degeneration, keratoglobus post kerato-refractive ectasia, and wound

ectasia after penetrating keratoplasty (PK). Corneal ectasias are

associated with decreased uncorrected visual acuity (UCVA), an increase

in ocular aberrations, and often a loss of best-corrected distance visual

acuity. Corneal ectasias can result in significant ocular morbidity and may

require surgical intervention … The diagnosis of corneal ectasia is usually

based on a typical patient history and characteristic findings on

topography and tomography … A comprehensive evaluation of both the

anterior and posterior surfaces (topographically and tomographically) as

well as full pachymetric mapping of the cornea is felt to be important in

establishing the diagnosis of corneal ectatic disease and following its

course. Slit-scanning corneal topography and Scheimpflug imaging

systems can evaluate these parameters and have expanded diagnostic

criteria for keratoconus, subclinical keratoconus, pellucid marginal

degeneration, and post kerato-refractive corneal ectasias. Their use are

necessary to properly screen potential refractive surgery patients … Prior

to refractive surgery, corneal topography and tomography performed

following a period of contact lens abstinence should be reviewed for

evidence of irregular astigmatism or abnormalities suggestive of

keratoconus or other forms of corneal ectasia”.

Evaluation of Keratoconus after Treatment with Penetrating


Keratoplasty

In an observational study, Ono and colleagues (2020) examined the

characteristics of anterior and posterior corneal topography in keratoconic

eyes more than 30 years after PK. Patients who maintained clear grafts

for more than 30 years after PK were included and divided into the

keratoconus (KC) group or other diseases (Others) group, based on the

primary indication; 26 eyes of 26 patients were included. The KC group

and the Others group included 14 eyes and 12 eyes, respectively. The

KC group subjects were younger at the time of surgery (p = 0.03). No

differences were observed in best-spectacle-corrected VA, keratometric

power, and central-corneal-thickness. Based on corneal topography

using Fourier harmonic analyses, regular astigmatism in the anterior

cornea was significantly larger (p = 0.047) and the spherical component

in the posterior cornea was significantly lower (p = 0.01) in the KC group.

The area under the receiver operating characteristic curve (AUC) of the

spherical component, regular astigmatism, asymmetry component, and

higher-order irregularity were 66.07 %, 63.10 %, 57.14 %, and 59.23 %,

respectively, in the anterior cornea and 80.65 %, 52.98 %, 63.10 %, and

63.99 %, respectively, in the posterior cornea. The authors concluded

that these findings suggested that Fourier harmonic analysis of corneal

topography could be useful for patients with KC long after PK. Moreover,

these researchers stated that prospective, clinical studies that examine

more items, compare the pre-operative and post-operative data, and

detect risk factors for recurrence ar e needed.

The authors stated that this study had several drawbacks. First, the study

design was retrospective, and the number of patients was small (n = 26)

owing to the rarity of patients who have maintained clear grafts for more

than 30 years after PK. These findings successfully disclosed significant

differences in some parameters with Fourier harmonic analysis, although

the small patient number could have resulted in a low detection power.

Second, the frequency at which corneal topographic analysis was

conducted was limited. With relatively stable corneal surfaces, patients

did not need to frequently visit a medical facility and undergo corneal

topographic analysis. Third, some patients underwent PK at another

institution and their data were unavailable for pre-operative and post-

operative comparison.


CPT Codes/ HCPCS Codes/ICD-10 Codes Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by “+”

Code Code Description CPT codes covered if selection criteria are met: 92025 Computerized corneal topography, unilateral or bilateral,

with interpretation and report Other CPT codes related to the CPB: 65710 - 65775 Keratoplasty and other corneal procedures 76514 Ophthalmic ultrasound, diagnostic; corneal pachymetry,

unilateral or bilateral (determination of corneal thickness) 92071 Fitting of contact lens for treatment of ocular surface

disease 92310 - 92326 Contact lens services HCPCS codes covered if selection criteria are met: Other HCPCS codes related to the CPB: S0592 Comprehensive contact lens evaluation S0810 Photorefractive keratectomy (PRK) S0812 Phototherapeutic keratectomy (PTK) ICD-10 codes covered if selection criteria are met: H11.001 - H11.069 Pterygium of eye H11.811 - H11.819 Pseudopterygium of conjunctiva H16.001 - H16.079 Corneal Ulcer H17.9 Unspecified corneal scar and opacity H18.10 - H18.13 Bullous keratopathy H18.461 - H18.469 Peripheral corneal degeneration [Terrien's marginal

degeneration] H18.50 - H18.59 Hereditary corneal dystrophies H18.601 - H18.629 Keratoconus H18.711 - H18.719 Corneal ectasia H52.211 - H52.219 Irregular astigmatism Q13.4 Other congenital corneal malformations [difficulty fitting

contact lens] T85.390+ - T85.398+ Other mechanical complication of other ocular prosthetic

devices, implants and grafts Z94.7 Corneal transplant status ICD-10 codes not covered for indications listed in the CPB (not all-inclusive): B60.10 - B60.13 Acanthamebiasis C69.00 - C69.02 Malignant neoplasm of conjunctiva [evaluation of ocular

surface squamous neoplasia] C69.10 - C69.12 Malignant neoplasm of cornea [evaluation of ocular

surface squamous neoplasia] D31.10 - D31.12 Benign neoplasm of cornea [limbal dermoids] D89.810 - D89.813 Graft-versus-host disease H16.141 - H16.149 Punctate keratitis


H16.221 – H16.229 Keratoconjunctivitis sicca, not specified as Sjögren's H16.301 - H16.399 Interstitial and deep keratitis H16.8 Other keratitis H18.421 - H18.429 Band keratopathy H18.451 - H18.459 Nodular corneal degeneration (e.g., Salzmann's nodular

dystrophy) H25.011 - H26.9 Cataract H27.111 - H27.139 Subluxation of lens H35.411 – H35.419 Lattice degeneration of retina H40.10 - H40.159 Open-angle glaucoma

• H52.00 – H52.209,

• H52.221 H52.7

Disorders of refraction and accommodation

H53.2 Diplopia Q11.2 Microphthalmus Q12.0 Congenital cataract Q87.40 - Q87.43 Marfan's syndrome

The above policy is based on the following references:

1. Agency for Healthcare Policy and Research (AHCPR), Cataract

Management Guideline Panel. Cataract in adults: Management of

functional impairment. Clinical Practice Guideline No. 4. AHCPR

Pub. No. 93-0542. Rockville, MD: AHCPR; February 1993.

2. American Academy of Ophthalmology (AAO) Glaucoma

Panel.Primary open-angleglaucoma. Preferred PracticePattern.

San Francisco, CA: AAO; October 2010.

3. American Academy of Ophthalmology (AAO), Anterior Segment

Panel. Cataract in the adult eye. Preferred Practice Pattern. San

Francisco, CA: AAO; 2006.

4. American Academy of Ophthalmology (AAO), Refractive Errors

Panel. Refractive errors & refractive surgery. Preferred Practice

Pattern. San Francisco, CA: AAO; October 2007.

5. American Academy of Ophthalmology (AAO). Corneal

opacification and ectasia. Preferred Practice Pattern. San

Francisco, CA: AAO; September 2000.

6. American Academy of Ophthalmology (AAO). Corneal

topography. Ophthalmology. 1999;106(8):1628-1638.

7. American Academy of Ophthalmology Cornea/External Disease

Panel.Preferred Practice Pattern®Guidelines. DryEyeSyndrome.

San Francisco, CA: American Academy of Ophthalmology; 2013.

8. Arroyo JG. Retinal detachment. UpToDate [online serial].


Waltham, MA: UpToDate; reviewed October 2018.

9. Baer AN. Diagnosis and classification of Sjogren's syndrome.

UpToDate [online serial]. Waltham, MA: UpToDate; reviewed

October 2018.

10. Caster AI, Friess DW, Schwendeman FJ. Incidence of epithelial

ingrowth in primary and retreatment laser in situ keratomileusis. J

Cataract Refract Surg. 2010;36(1):97-101.

11. Cavas-Martinez F, De la Cruz Sanchez E, Nieto Martinez J, et al.

Corneal topography in keratoconus: State of the art. Eye Vis

(Lond). 2016;3:5.

12. Choi JA, Kim MS. Progression of keratoconus by longitudinal

assessment with corneal topography. Invest Ophthalmol Vis Sci.

2012;53(2):927-935.

13. de Paiva CS, Lindsey JL, Pflugfelder SC. Assessing the severity of

keratitis sicca with videokeratoscopic indices. Ophthalmology.

2003;110(6):1102-1109.

14. Garcia-Ferrer FJ, Akpek EK, Amescua G, et al; American Academy of

Ophthalmology Preferred Practice Pattern Cornea and External

Disease Panel. Corneal Ectasia Preferred Practice Pattern.

Ophthalmology. 2019;126(1):P170-P215.

15. Goggin M, Alpins N, Schmid LM. Management of irregular

astigmatism.Curr Opin Ophthalmol. 2000;11(4):260-266.

16. Gokul A, Vellara HR, Patel DV. Advanced anterior segment

imaging in keratoconus: A review. Clin Exp Ophthalmol.

2018;46(2):122-132.

17. Hu PH, Gao GP, Yu Y, et al. Analysis of corneal topography in

patients with pure microphthalmia in Eastern China. J Int Med

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18. Majmudar PA. Keratitis, interstitial. eMedicine Ophthalmology

Topic 101. Omaha, NE: eMedicine.com; updated January 31, 2001.

Available at: http://www.emedicine.com/oph/topic101.htm. Accessed

July 9, 2003.

19. Morrow GL, Stein RM. Evaluation of corneal topography: Past,

present and future trends. Can J Ophthalmol. 1992;27(5):213-

225.

20. Ono T, Kawasaki Y, Chen LW, et al. Corneal topography in

keratoconus evaluated more than 30 years after penetrating

keratoplasty: A Fourier harmonic analysis. Sci Rep.

2020;10(1):14880.

21. Oshika T, Klyce SD. Corneal topography in LASIK. Semin

Ophthalmol. 1998;13(2):64-70.

22. Rao SK, Padmanabhan P. Understanding corneal topography.

Curr Opin Ophthalmol. 2000;11(4):248-259.

http://www.emedicine.com/oph/topic101.htm

http://eMedicine.com


23. Rapuano CJ. Management of epithelial ingrowth after laser in situ

keratomileusis on a tertiary care cornea service. Cornea.

2010;29(3):307-313.

24. Sade de Paiva C, Lindsey JL, Pflugfelder SC. Assessing the severity of

keratitis sicca with videokeratoscopic indices. Ophthalmology.

2003;110(6):1102-1109.

25. Sanders DR, Gills JP, Martin RG. When keratometric

measurements do not accurately reflect corneal topography. J

Cataract Refract Surg. 1993;19 Suppl:131-135.

26. Seitz B, Behrens A, Langenbucher A. Corneal topography. Curr

Opin Ophthalmol. 1997;8(4):8-24.

27. Sherwin T, Brookes NH. Morphological changes in keratoconus:

Pathology or pathogenesis. Clin Experiment Ophthalmol.

2004;32(2):211-217.

28. Sultan G, Baudouin C, Auzerie O, et al. Cornea in Marfan disease:

Orbscan and in vivo confocal microscopy analysis. Invest

Ophthalmol Vis Sci. 2002;43(6):1757-1764.

29. Tummanapalli SS, Potluri H, Vaddavalli PK, Sangwan VS. Efficacy of

axial and tangential corneal topography maps in detecting

subclinical keratoconus. J Cataract Refract Surg.

2015;41(10):2205-2214.

30. Visser N, Berendschot TT, Verbakel F, et al. Comparability and

repeatability of corneal astigmatism measurements using

different measurement technologies. J Cataract Refract Surg.

2012;38(10):1764-1770.

31. WaymanLL. Keratoconus. UpToDate [online serial]. Waltham,

MA: UpToDate; reviewed November 2015.

32. White ML, Chodosh J. Herpes simplex virus keratitis: A treatment

guideline – 2014. San Francisco, CA: American Academy of

Ophthalmology; June 2014. Available at:

https://www.aao.org/clinical-statement/herpes-simplex-virus-

keratitis-treatment-guideline. Accessed October 8,2018.

33. Wilson SE, Ambrisio R. Computerized corneal topography and its

importance to wavefront technology. Cornea. 2001;20(5):441-454.

34. Wilson SE, Klyce SD. Advances in the analysis of corneal

topography. Surv Ophthalmol.1991;35(4):269-277.

35. Wolffsohn JS, Peterson RC. Anterior ophthalmic imaging. Clin Exp

Optom. 2006;89(4):205-214.

https://www.aao.org/clinical-statement/herpes-simplex-virus-keratitis-treatment-guideline

https://www.aao.org/clinical-statement/herpes-simplex-virus-keratitis-treatment-guideline


Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and

constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or

program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any

results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna

or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be

updated and therefore is subject to change.

Copyright © 2001-2022 Aetna Inc.


AETNA BETTER HEALTH® OF PENNSYLVANIA

Amendment to Aetna Clinical Policy Bulletin Number: 0130 Computerized Corneal

Topography

There are no amendments for Medicaid.

Annual 04/01/2022

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Computerized Corneal Topography - Aetna Better Health