CMS Modified NCD 72 for refractive keratoplasty, effective March 7, 2026. Here's what billing teams need to know before submitting claims for corneal surgery.
The Centers for Medicare & Medicaid Services updated National Coverage Determination NCD 72, which governs the CMS refractive keratoplasty coverage policy. This modification clarifies the line between non-covered refractive procedures and covered therapeutic corneal surgeries — a distinction that directly affects claim denial rates for ophthalmology billing teams. No specific CPT or HCPCS codes are listed in this policy document, but the coverage rules apply to any procedure that falls under the refractive keratoplasty umbrella.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | CMS (Centers for Medicare & Medicaid Services) |
| Policy | Refractive Keratoplasty — NCD 72 |
| Policy Code | NCD 72 |
| Change Type | Modified |
| Effective Date | March 7, 2026 |
| Impact Level | Medium |
| Specialties Affected | Ophthalmology, Optometry, Corneal Surgery |
| Key Action | Audit all corneal surgery claims to confirm the documented diagnosis supports therapeutic — not refractive — intent before billing Medicare |
CMS Refractive Keratoplasty Coverage Criteria and Medical Necessity Requirements 2026
The core rule here is simple: Medicare does not cover surgery that corrects refractive error as a substitute for glasses or contact lenses. That's been true for years. What this updated coverage policy reinforces is the specific statutory basis for that exclusion — and where the narrow exceptions live.
Medicare excludes refractive correction under two separate statutory provisions. Section §1862(a)(7) of the Social Security Act excludes eyeglasses and contact lenses. Section §1862(a)(10) excludes cosmetic surgery. CMS applies both exclusions to refractive keratoplasty, meaning a claim can get denied on either ground — or both.
The procedures covered under NCD 72 Medicare include three main surgical types. Keratomileusis removes, reshapes, and reattaches the front of the cornea to correct myopia or hyperopia. Keratophakia inserts a reshaped donor cornea to treat farsightedness. Radial keratotomy cuts spoke-like slits in the cornea to flatten it and correct nearsightedness. All three are non-covered when performed to correct refractive error.
Where Medical Necessity Does Apply
The exception is narrow but real. Keratoplasty that treats a specific lesion or abnormality of the cornea — rather than refractive error — can be covered under §1862(a)(1)(A), the medical necessity provision.
The policy cites phototherapeutic keratectomy as a clear example. When phototherapeutic keratectomy removes scar tissue from the visual field, it addresses an anatomical abnormality of the eye. That's not cosmetic. That's not a substitute for glasses. That's medical necessity — and it's coverable. Your documentation needs to reflect that distinction explicitly.
This is where many ophthalmology billing teams run into trouble. The surgical technique may look identical on the operative note. The difference lives in the diagnosis: why was this procedure performed? If the answer is "to reduce the patient's dependence on corrective lenses," Medicare won't pay. If the answer is "to remove corneal scar tissue obstructing the visual axis," you have a covered claim — provided you document it correctly.
Prior authorization is not explicitly required under NCD 72, but that doesn't mean you're clear of pre-claim scrutiny. Medicare Administrative Contractor post-payment reviews target ophthalmology claims regularly. Treat your documentation as if prior authorization were required.
Laser Procedures and Practitioner Qualifications
NCD 72 includes one more requirement that billing teams often overlook. When lasers are used to treat ophthalmic disease, CMS classifies that as ophthalmologic surgery. Coverage is restricted to practitioners who have completed an approved training program in ophthalmologic surgery.
This matters for reimbursement. If a claim for a laser-based corneal procedure goes through without verification of the operating provider's qualifications, you're exposed to post-payment recoupment. Confirm the billing provider's credentials before you submit.
CMS Refractive Keratoplasty Exclusions and Non-Covered Indications
The exclusions under NCD 72 are broad and explicitly statutory. They're not soft clinical guidelines — they're written into the law.
Radial keratotomy to correct nearsightedness is not covered. Keratomileusis to correct myopia or hyperopia is not covered. Keratophakia to correct farsightedness is not covered. Any procedure performed to reduce dependence on corrective lenses is not covered.
The policy also reinforces that many in the medical community classify these procedures as cosmetic surgery. CMS agrees with that classification for refractive purposes, which means the §1862(a)(10) cosmetic surgery exclusion applies as a second layer of denial justification.
This dual statutory exclusion is unusual and worth flagging to your billing team. A payer can deny on medical necessity grounds, cosmetic surgery grounds, or both. Appeals need to address both arguments. If you're appealing a denied claim for a corneal procedure, loop in your compliance officer before you submit the appeal to make sure you're responding to the right statutory basis.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Radial keratotomy for myopia (nearsightedness) | Not Covered | Not specified in policy | Excluded under §1862(a)(7) and §1862(a)(10) |
| Keratomileusis for myopia or hyperopia | Not Covered | Not specified in policy | Excluded as substitute for eyeglasses/contact lenses |
| Keratophakia for hyperopia (farsightedness) | Not Covered | Not specified in policy | Excluded under §1862(a)(7) and §1862(a)(10) |
| Refractive keratoplasty for refractive error correction (general) | Not Covered | Not specified in policy | Any procedure serving as alternative to corrective lenses is excluded |
| Phototherapeutic keratectomy to remove corneal scar tissue | Covered | Not specified in policy | Covered under §1862(a)(1)(A) — medical necessity, not cosmetic; diagnosis must document corneal pathology |
| Keratoplasty treating specific corneal lesions or abnormalities | Covered | Not specified in policy | Must document anatomical abnormality — not refractive intent |
| Laser ophthalmologic surgery for ophthalmic disease | Covered with Restrictions | Not specified in policy | Provider must have completed approved ophthalmologic surgery training program |
| Cataract surgery-related keratoplasty | Potentially Covered | Not specified in policy | Policy references an exception "in certain cases in connection with cataract surgery" — verify separately |
CMS Refractive Keratoplasty Billing Guidelines and Action Items 2026
The effective date of March 7, 2026 means this updated coverage policy is already active. If your team hasn't reviewed your ophthalmology billing workflow against NCD 72 criteria, do it now.
| # | Action Item |
|---|---|
| 1 | Audit your ophthalmology charge capture for diagnosis specificity. Every corneal surgery claim billing Medicare needs a diagnosis code that reflects a therapeutic indication — corneal scar, corneal opacity, corneal pathology — not just refractive error. If your coders are pulling ICD-10 codes for myopia or hyperopia as the primary diagnosis on these claims, those claims are going to be denied. |
| 2 | Separate refractive and therapeutic intent at the encounter level. Work with your clinical documentation team to make sure operative notes distinguish therapeutic procedures (removing pathological tissue) from refractive procedures (correcting vision errors). Ambiguous documentation defaults to a denial. Don't leave it ambiguous. |
| 3 | Verify provider credentials for any laser-based corneal procedure before billing. NCD 72 restricts laser ophthalmologic surgery reimbursement to practitioners with completed approved training in ophthalmologic surgery. Confirm this before the claim goes out. A mismatch between the procedure billed and the provider's credentials is a straightforward recoupment risk. |
| 4 | Flag cataract surgery claims that involve corneal procedures. The policy notes an exception for keratoplasty "in certain cases in connection with cataract surgery." This exception is vague. If your practice performs combined cataract and corneal procedures, talk to your billing consultant or compliance officer about how to document and bill that combination correctly under NCD 72. |
| 5 | Pull and review any denied claims from the past 12 months involving corneal surgery. If you're seeing claim denial patterns on keratoplasty or keratectomy procedures, review the denial reason codes. Denials citing cosmetic surgery exclusions or refractive error exclusions need different appeal strategies. Don't use a generic medical necessity appeal for a cosmetic surgery denial — it won't work. |
| 6 | Don't assume absence of prior authorization means absence of scrutiny. NCD 72 doesn't mention prior authorization requirements, but Medicare Administrative Contractor reviews of ophthalmology claims are common. Build your documentation as if you'll face a post-payment audit. If you're unsure how your local MAC interprets these billing guidelines, check their local coverage determination (LCD) policies or contact them directly. |
| 7 | Review your refractive keratoplasty billing across the full procedure spectrum. Your team may be billing a mix of therapeutic and refractive procedures. The therapeutic ones can be covered. The refractive ones cannot. Make sure your billing workflow routes each claim through the right review path based on documented intent — not just procedure name. |
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for Refractive Keratoplasty Under NCD 72
A Note on Code Availability
NCD 72 does not list specific CPT codes, HCPCS codes, or ICD-10-CM codes. This is not unusual for older National Coverage Determinations — NCD 72 establishes the coverage rule on a functional basis rather than tying it to specific code sets.
That creates a practical challenge for refractive keratoplasty billing. You need to map your charge capture to the coverage criteria yourself. Work with your coding team or billing consultant to identify the specific CPT codes your practice uses for keratomileusis, keratophakia, radial keratotomy, and phototherapeutic keratectomy — then map each code to a covered or non-covered indication based on the NCD 72 rules above.
The coverage criteria, not the code, determines whether Medicare pays. A CPT code for phototherapeutic keratectomy billed with a refractive error diagnosis will be denied just as fast as any other non-covered claim. The diagnosis and documentation carry the weight here.
If your MAC has issued a local coverage determination that references specific codes for corneal procedures, that LCD overrides or supplements NCD 72 at the regional level. Pull your MAC's LCD for corneal surgery procedures to get code-level specificity.
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