Top insurer reverses policy, agrees to cover DSEK, DSAEK

The initial policy said the procedures were investigational after a new CPT code was issued.

At the urging of ophthalmology advocates, a large insurance carrier reversed its decision to not cover a relatively new but widely accepted corneal transplant procedure.

Anthem-WellPoint had instituted a policy under which it would not cover Descemet’s stripping endothelial keratoplasty (DSEK) and Descemet’s stripping automated endothelial keratoplasty (DSAEK), effective Jan. 1, according to the American Academy of Ophthalmology.

However, in early February, the company agreed to cover DSEK and DSAEK after a conference call with AAO officials. The AAO had also submitted scientific evidence supporting the use of endothelial keratoplasty (EK), Michael X. Repka, MD, AAO secretary of federal affairs, said in a statement.

“We’re very pleased that in response to the Academy’s earlier submission of scientific evidence about EK and a recent conference call with Anthem-WellPoint to discuss the issue, the insurer has agreed to cover Descemet’s stripping endothelial keratoplasty, effective immediately,” Dr. Repka said.

New policy

Anthem-WellPoint and some other insurance carriers deemed EK investigational, despite the issuance of a new CPT code and Medicare coverage of the procedure, Dr. Repka said.

“The Academy, along with the Cornea Society and the Eye Bank Association of America, has been pressing third-party payers to recognize the use of this surgery, which provides significant patient benefits,” he said. “[The] decision by Anthem underscores the significance of the evidence in favor of this procedure. The Academy also discussed DSEK coverage with Aetna recently; they will be reviewing its policy by the end of [February].”

Anthem-WellPoint’s new medical policy deems DSEK and DSAEK medically necessary for treating corneal diseases such as Fuchs’ dystrophy and aphakic and pseudophakic bullous keratopathy (corneal edema following cataract removal), and failure or rejection of previous corneal transplants, according to a summary of the policy provided by Jill A. Becher, Anthem-WellPoint corporate communications director.

“WellPoint’s medical policies are intended to reflect the current scientific data and clinical thinking,” Ms. Becher said. “While medical policy will make assessments regarding the medical necessity of individual technologies, etc., federal and state law, as well as contract language, including definitions and specific contract provisions, take precedence over medical policy and must be considered first in determining eligibility for coverage.”

Medicare code

“Because of its widespread use, the Academy thought we definitely needed a code for [EK],” Francis W. Price Jr., MD, an OSN Corneal/External Disease Board Member, said. “For better or for worse, we got a new [Medicare] code that was effective Jan. 1. Anthem, seeing that a new code was coming out, came out with a ruling effective Jan. 1 that they weren’t going to pay for endothelial keratoplasty, specifically DSEK and DSAEK.”

Anthem-WellPoint seemed to miss some larger peer-reviewed studies that supported the safety and effectiveness of DSEK and DSAEK and used inconclusive early data to support its initial decision, Dr. Price said.

“For instance … they did not reference our article that had 2-year endothelial cell count data showing that [EK] was doing about as well as a PK for endothelial cell survival.”

Under the original policy, Anthem-WellPoint would have covered PK, but not DSEK or DSAEK, Dr. Price said.

“There are certainly complications and problems with all the endothelial keratoplasties, no doubt about it,” he said. “That’s what these articles were about that they referenced. On the other hand, there are even worse complications with penetrating keratoplasty.”

Anthem-WellPoint changed its policy after realizing that PK has a higher complication rate than EK, Dr. Price said. DSEK and DSAEK involve a lower risk of postoperative wound rupture and intraoperative suprachoroidal hemorrhage than PK, he said. – by Matt Hasson

• Jill A. Becher can be reached at WellPoint, N17 W24340 Riverwood Drive, Waukesha, WI 53188; 262-523-4764; fax: 262-523-4772; e-mail: jill.becher@bcbswi.com.
• Francis W. Price Jr., MD, can be reached at Price Vision Group, 9002 N. Meridian St., Suite 100, Indianapolis, IN 46260; 317-844-5530; fax: 317-844-5590; e-mail: fprice@pricevisiongroup.net.
• Michael X. Repka, MD, can be reached at Wilmer Ophthalmological Institute, 600 N. Wolfe St., John Hopkins Hospital, Baltimore, MD 21287-9028; 410-955-8314; fax: 410-955-0809; e-mail: mrepka@jhmi.edu.