CROSS-LINKING REIMBURSEMENT:SPONSORED BY

A CASE STUDY IN HOW THE PROCESS WORKS

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 in their practices.
BRANDON D. AYRES, MDnS urgeon on the Cornea Service, Wills Eye Hospital,Philadelphia, PAnF
 inancial disclosure: Consultant (Avedro)delighted that Avedro is being aggressive.
We are fortunate that major societies—the American Academyof Ophthalmology (AAO), the American Society of Cataract andRefractive Surgery (ASCRS), and the Cornea Society—agree thatCXL is a medically indicated treatment for a disease and should be
reimbursed by insurers (Figure 1).

KATHRYN M. HATCH, MDnA
 ssistant Professor of Ophthalmology at Harvard Medical
School, Boston, MA; Director, Refractive Surgery Service;
Site Director, Massachusetts Eye and Ear, Waltham, MAnF
 inancial disclosure: Consultant (Avedro)

Dr. Rajpal: Dr. Hatch, what was your experience with reimbursement challenges faced at Massachusetts Eye and Ear, andhow did you overcome them?

RICHARD L. LINDSTROM, MDnF
 ounder and Attending Surgeon, Minnesota EyeConsultants, 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 Practice Management Consultant,Philadelphia, PAnF
 inancial disclosure: Consultant (Avedro)ALLISON W. SHUREN, MSN, JDnP artner and Co-Chair of the Life Sciences and Healthcare
Regulation Practice, Arnold & Porter, Washington, DCnF
 inancial disclosure: Consultant (Avedro)

COLLABORATING WITH INSURANCE COMPANIESDr. Rajpal: Reimbursement challenges are common with any
new medical procedure. Dr. Lindstrom, describe your experience
with insurance reimbursement for corneal cross-linking (CXL).
Dr. Lindstrom: This is not the first time we have had to fight
this battle in ophthalmology, and physicians have to be involved.
At a minimum, we must write supporting letters, and often weneed to make phone calls. In my practice, we are encouraging ourpatients to be aggressive with their insurance carriers, and we areDr. Hatch: As with any new procedure, we must proactively
educate the patients, our community physicians, and the insurance companies. Typically, insurance companies approve the procedure, but then they do not know how to pay for it.
At Massachusetts Eye and Ear, Blue Cross Blue Shield ofMassachusetts covered the procedure and many treatments wereapproved, but we were not being paid initially. The company
came to us to make a recommendation for what coverage would
be, and we wrote a detailed letter explaining the procedure andemphasizing its benefits.
Initially, the reimbursement rate was disappointing. They weretrying to find “treat-like” codes and were comparing CXL to procedures that are not at all comparable, such as pachymetry, removalof epithelium, and phototherapy for vitiligo.
In a call with Blue Cross Blue Shield, we explained that CXL is aground-breaking procedure that involves a huge amount of chairtime. We stressed that we are trying to stop the progression of avision-threatening disease in adolescents over the age of 14 andthat comparing keratoconus to vitiligo is not appropriate.
After that discussion, they set a favorable reimbursement rate,
and they are covering both the J and T codes in Massachusetts.
That was a success story for us. We are hoping that other insurers
will follow, but I think we will have to work with each one individually. It is time-consuming but necessary.
Dr. Ayres: Nothing will change unless we help make it change.
I have been on the phone for an hour or two waiting to talk to a
medical director. In many cases, the director is a family practitioner
who has never heard of keratoconus. We have to fight the fight.

J CODE DECISION
Dr. Rajpal: How can we manage some of the uncertainty
around the J code?
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Figure 1. An increasing number of commercial payers begin to recognize the medical necessity of CXL.

Ms. Rapuano: I recommend following the suggested guidelines
posted on the AAO website (https://www.aao.org/practicemanagement/news-detail/how-to-bill-corneal-cross-linking).
Basically, you should submit a predetermination letter to theinsurer for both the T code and the unspecified J code. By doing
this, you can confirm that the insurer is comfortable with the twocodes and also that your patient meets the insurer’s medical policy
guidelines. At Wills Eye, carriers have told us this approach makes
sense, because it is similar to our claims for intravitreal injections,where we submit the procedure code and the drug code.
The Centers for Medicare and Medicaid Services recently issued apreliminary decision to establish a new J code specific to Photrexa
Viscous and Photrexa (Avedro), which should streamline the claims
submission process. This preliminary decision is expected to be
finalized in November 2018 and effective January 2019.
For now, current billing practice remains unchanged, and amiscellaneous J code (J3490), as suggested by the American
Academy of Ophthalmology, remains an option to bill for Photrexa.
Photrexa is a trademark of Avedro. © 2018 Avedro. All other brand/productnames are the trademarks of their respective owners.

While payment is not guaranteed, providing the carrier withinformation up front about the procedure, the cost of the drug,
and how you plan to submit the claim is beneficial. Your patients
will know that you have gone the extra mile for them. What’smore, every claim we submit will help change those policies sothat everyone gets access eventually.
Dr. Rajpal: Are there legal ramifications we should be aware of?
Ms. Shuren: I advise my physician clients to be as transparent
as possible with payers to avoid unnecessary audits or allegationsof fraud.
The approach Ms. Rapuano outlined is supported by the AAO,
and I believe the ASCRS concurs. Hopefully, they will issue written
guidelines soon, which is good evidence of what the medical community thinks is the right thing to do.
Dr. Rajpal: We have information that the J code has been recommended for approval. Should practices do anything differently?
Ms. Shuren: If a new code is issued, it will not be available until
January 2019, so just keep using the unspecified code. That continues to feed information into the system until such time as aspecific J code becomes available. nIMPORTANT 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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