Refractive Keratoplasty — NCD 72 | CMS Coverage Update

TL;DR: The Centers for Medicare & Medicaid Services modified NCD 72, the National Coverage Determination governing refractive keratoplasty under Medicare, effective March 7, 2026. Here's what changes for billing teams.

CMS refractive keratoplasty coverage policy under NCD 72 draws a hard line: Medicare does not cover radial keratotomy, keratomileusis, or keratophakia when performed to correct refractive errors like myopia or hyperopia. The policy does carve out a narrow covered exception — keratoplasty that treats actual corneal lesions or pathology. The NCD 72 Medicare policy has no specific CPT or HCPCS codes listed, which creates real documentation risk for ophthalmic billing teams who don't understand where the line sits.

Quick-Reference Table

CMS Refractive Keratoplasty Coverage Criteria and Medical Necessity Requirements 2026

The core rule here is simple. Medicare excludes coverage for refractive keratoplasty when the clinical purpose is correcting a common refractive error. That includes myopia, hyperopia, and the procedures designed to fix them — radial keratotomy, keratomileusis, and keratophakia.

CMS grounds this exclusion in two statutory sections. Section 1862(a)(7) of the Social Security Act excludes eyeglasses, contact lenses, and devices that substitute for them. CMS treats refractive keratoplasty as exactly that — a substitute for corrective lenses. Section 1862(a)(10) excludes cosmetic surgery, and CMS notes that many in the medical community classify these refractive procedures as cosmetic.

The covered exception is narrower than most billing teams realize. Keratoplasty that treats a specific lesion of the cornea — the policy specifically cites phototherapeutic keratectomy to remove scar tissue from the visual field — does meet the medical necessity standard. The clinical distinction is whether you're treating an abnormality of the eye or correcting a refractive defect. Those are not the same thing, and Medicare will not treat them as interchangeable.

Prior authorization is not explicitly mentioned in NCD 72, but that doesn't reduce your documentation burden. Medical necessity must be established through the clinical record before you bill. If your documentation only shows the patient's refractive error and desired visual acuity improvement, you're setting up a claim denial.

The coverage policy also carries a specific requirement for laser procedures. When lasers are used to treat ophthalmic disease — which CMS classifies as ophthalmic surgery — coverage applies only to practitioners who have completed an approved training program in ophthalmologic surgery. If your practice bills for laser-based keratoplasty under the covered exception, the provider's credentials must be in order. An unqualified provider performing an otherwise covered procedure is still a non-covered claim.

CMS Refractive Keratoplasty Exclusions and Non-Covered Indications

The exclusions in NCD 72 are broad and explicitly statutory. This isn't a local coverage determination — it's a national policy with no regional flexibility.

Radial keratotomy for nearsightedness correction is not covered. Keratomileusis for near or farsightedness correction is not covered. Keratophakia for farsightedness correction is not covered. CMS is explicit: these procedures are substitutes for eyeglasses and contact lenses, both of which Medicare excludes under §1862(a)(7).

The cosmetic surgery angle matters too. CMS flags the medical community's classification of these procedures as cosmetic — adding a second statutory basis for exclusion under §1862(a)(10). That dual exclusion is relevant if you're ever appealing a denied claim. You're not fighting one exclusion. You're fighting two.

Refractive keratoplasty billing on a Medicare claim without documented corneal pathology will result in claim denial. There's no gray area here. The procedure purpose — not the procedure itself — determines coverage.

Coverage Indications at a Glance

CMS Refractive Keratoplasty Billing Guidelines and Action Items 2026

CPT, HCPCS, and ICD-10 Codes for Refractive Keratoplasty Under NCD 72

The NCD 72 policy document does not list specific CPT, HCPCS, or ICD-10 codes. This is a known limitation of the policy as published by CMS, and it creates real operational complexity for refractive keratoplasty billing teams.

What This Means for Your Billing Team

Without a defined code list in the policy itself, coverage determinations under NCD 72 depend entirely on clinical documentation and the stated purpose of the procedure. Your Medicare Administrative Contractor (MAC) may have supplemental guidance or a local coverage determination (LCD) that provides code-level specificity. Check with your MAC directly.

The absence of a code list does not reduce your exposure. It increases it. Any keratoplasty procedure billed to Medicare — regardless of code — is subject to the NCD 72 coverage rules. The clinical indication documented in the record is what CMS auditors and MACs will review.

Checking MAC-Level Guidance

Because NCD 72 carries no code list, your MAC's LCD for ophthalmic surgery procedures is the next place to look. MACs frequently publish LCDs that translate national coverage determinations into code-level billing instructions. Contact your MAC or search the CMS Medicare Coverage Database for LCDs in your jurisdiction that reference corneal surgery or phototherapeutic keratectomy.

If you're unsure which MAC handles your claims — or whether your MAC has issued supplemental guidance that narrows or clarifies NCD 72 — your compliance officer or billing consultant should pull that documentation before the effective date of March 7, 2026.