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CXL AND INSURANCE: A HOW-TO GUIDE
Avedro gathered leading refractive surgeons and eye care professionals for a roundtable discussion during the 2018 annual meetingof the American Society of Cataract and Refractive Surgery in Washington, DC. The discussion centered around current issues
experienced by ophthalmologists who perform corneal cross-linking (CXL) in their practices.

BRANDON D. AYRES, MDnS urgeon on the Cornea
Service, Wills Eye Hospital,Philadelphia, PAnF
 inancial disclosure:
Consultant (Avedro)
KATHRYN M. HATCH, MDnD
 irector, Refractive Surgery
Service, Massachusetts
Eye and Ear; Site Director,
Massachusetts Eye and Ear,Waltham, MA; AssistantProfessor of Ophthalmology
at Harvard Medical School,Boston, MAnF
 inancial disclosure:
Consultant (Avedro)
RICHARD L. LINDSTROM, MDnF
 ounder and Attending
Surgeon, Minnesota Eye
Consultants, Minneapolis, MNnF
 inancial disclosure:
Consultant (Avedro)
RAJESH K. RAJPAL, MDnF
 ounder, See Clearly Vision
Group Tysons Corner, VAnF
 inancial disclosure: Chief
Medical Officer, Avedro
SARA B. RAPUANO, MBA, CPC,COE, OCSnO
 phthalmology PracticeManagement Consultant,Philadelphia, PAnF
 inancial disclosure:
Consultant (Avedro)

MA-01117AHOW DO YOU DISCUSS CXL AND
INSURANCE COVERAGE WITH YOURPATIENTS?
Dr. Ayres: First, I confirm the patient
has progressive keratoconus and makesure everyone is in agreement about theimportance of treatment and stopping
progression. I explain that the US Foodand Drug Administration (FDA) has
approved CXL, but that FDA approval
does not always mean a procedure isinitially covered by insurance. I also tellpatients that we have had success getting insurance carriers to approve coverage for CXL during the past year andthat we will try our best to do the samefor them. Then I transfer the discussion
to our CXL coordinator.
Coordinators need to be sensitive tothe fact that this is a new diagnosis for asomewhat frightened patient. Their role
is to reassure patients that we will makeevery effort to get coverage. They should
also explain that we may not have ananswer for a couple of weeks, so thesooner we start the process, the sooner
the patient can be treated.
Dr. Hatch: We keep a list of all local
insurance carriers that have publishedpositive or negative coverage guidelines. When patients agree to CXL, weassure them that we will do everything
we can to get the procedure covered.
Initially we submit a prior authorization
and appeal denied claims. I empower
the patient and educate them thatthey are a customer of their insurancecompany, and if it is an employer-basedplan to have them contact their humanresources benefits team because weneed them to voice their concernsregarding coverage.

Dr. Lindstrom: We are fortunate tohave an engaged company like Avedro towork with. That has made a huge difference, and it is great that our societies andthe National Keratoconus Foundation areon board. It is also helpful when patients
aggressively seek reimbursement.
In our practice, we have gone from zero
to about 60% of CXL surgeries reimbursed,
so we are moving the needle. This battle
is similar to what we have seen with othernew technologies.

HOW DO YOU EXPLAIN THE
CONSEQUENCES OF WAITING FOR
COVERAGE?
Dr. Lindstrom: One of our biggest challenges is how to respond to patients whoask if their insurance company could possibly cover CXL within the next year. I tellthem it is possible, but their condition isworsening and therefore not in their bestinterest to wait.
Dr. Hatch: I tell patients that CXL is the
only treatment known to limit diseaseprogression and preserve vision. The timeof treatment is the starting place. I informthem that if they wait 6 months and thedisease progresses, then unfortunately thatwould be their new starting place, and I
cannot ensure that I can bring their eyeback to where it was before.

HOW DO YOU HANDLE INITIAL LOWPAYMENTS FROM PAYERS?
Ms. Rapuano: Our local Blue Cross
Blue Shield (BCBS) has a positive coverage policy for CXL, but they were slow topay because they did not know how toprice it. We have to educate payers on thecost and work involved, along with theresources in providing this service.

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An increasing number of commercial payers begin to recognize the medical necessity of CXL. For updated insurance information,
visit www.avedro.com.

Dr. Hatch: At Massachusetts Eye andEar, we received numerous approvals
for both the J and T codes by BCBS ofMassachusetts, the state’s largest insurer,
but months passed with no payments oneither code after procedures had beenperformed. Getting approval and getting paid are not one in the same with
the insurance companies. Ultimately,
BCBS asked us to recommend the dollar
amount for reimbursement. We wrote a
detailed letter explaining the procedureand highlighting its benefits. Initially,the proposed reimbursement rate wasdisappointing. We were able to set up
a conference call with them, and weemphasized that CXL is a ground-breaking procedure unlike any other, involving
many resources, such as office labor, capital equipment expenditures, and face-toface chair time with the patients—commonly adolescents—and their families.

They seemed to listen to what we said,
and they set a favorable reimbursement
rate. They are now covering both the Jcode and the T code in Massachusetts.
That is a success story for us.
Dr. Ayres: Nothing will change unless
we help make it change. I have often
spent up to 2 hours on the phone waiting to talk to a medical director at aninsurance company. In many cases, thedirector is a family practitioner who has
never heard of keratoconus. We haveto fight the fight, and eventually we will
make a difference in reimbursement.

WHEN IS IT ACCEPTABLE FOR PRACTICESTO CHARGE UP FRONT FOR CXL?
Ms. Rapuano: If an insurer has apositive coverage policy, you can only
collect the appropriate co-insurance
and deductible for the procedure. It isimportant to note that you
should verify the patient's
condition is advanced enoughto fall within the coverageguidelines. If an insurer has anegative coverage policy, you
may submit a predetermination
letter asking the carrier toreconsider their policy for yourpatient. In this case, it would beappropriate to collect your feesup front. You should have thepatient sign a Notice of Exclusionfrom Health Plan Benefits form.
If the insurer denies the claim,
then you have protected yourpractice. The provider and thepatients have the right to appeal a denied
claim, so it is important to submit claims
for people who have negative coveragepolicies.
When an insurer is silent, we suggestthat you also ask for a prior authorizationor predetermination. The process is thesame as for a negative coverage policy.
The patient may be asked to pay up
front, but they have the right to appeal
if the claim is denied. We recommend
submitting these claims and really fighting for coverage for that patient—and allof the keratoconus patients who comeafter—to help change those policies. Thisis a team effort, and the involvement ofpatients and parents will help us influence those insurance companies. Tacklingthem from both ends helps to get thosepolicies changed. Note to Reader: Bestpractice is to ask for a specialty match
when requesting a peer-to-peer review. n

IMPORTANT SAFETY INFORMATION
INDICATIONSPHOTREXA® VISCOUS (riboflavin 5’-phosphate in 20% dextran ophthalmic solution) and Photrexa® (riboflavin 5’-phosphate ophthalmic solution) are indicated for use with the KXL System in corneal
collagen cross-linking (CXL) for the treatment of progressive keratoconus and corneal ectasia following refractive surgery.
LIMITATIONS OF USE
The safety and effectiveness of CXL has not been established in pregnant women, women who are breastfeeding, patients who are less than 14 years of age and patients 65 years of age or older.
Photrexa Viscous and Photrexa should be used with the KXL System only.
WARNINGS AND PRECAUTIONS
Ulcerative keratitis can occur. Patients should be monitored for resolution of epithelial defects.
ADVERSE REACTIONSIn progressive keratoconus patients, the most common ocular adverse reactions in any CXL treated eye were corneal opacity (haze), punctate keratitis, corneal striae, corneal epithelium defect, eye pain,
reduced visual acuity, and blurred vision. In corneal ectasia patients, the most common ocular adverse reactions were corneal opacity (haze), corneal epithelium defect, corneal striae, dry eye, eye pain,
punctate keratitis, photophobia, reduced visual acuity, and blurred vision.
These are not all of the side effects of Photrexa® Viscous, Photrexa® and the CXL treatment. For more information, see Prescribing Information (http://avedro.com/wp-content/uploads/ML-00043B.pdf).
You may report an adverse event to Avedro by calling 1-844-528-3376, Option 1 or you may contact the U.S. Food and Drug Administration (FDA) directly at 1-800-FDA-1088.

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