Corneal cross-linking is a procedure used to treat keratoconus, a condition that causes the cornea to lose its shape. Keratoconus can be a lifelong condition, but corneal cross-linking involves the use of eye drop medication and UV light to strengthen your eye and prevent the condition from worsening. (Learn More)

Corneal cross-linking is not a cheap procedure. It generally costs $2,500 to $4,000 per eye.

There are two types of corneal cross-linking: epithelium-off cross-linking and epithelium-on cross-linking, but only epithelium-off cross-linking is presently FDA approved. This means that insurance companies will usually cover epithelium-off cross-linking, but they almost never cover epithelium-on cross-linking. (Learn More)

Some people are frustrated that epi-on cross-linking is not covered by insurance, as it tends to be less painful and has less risk of complications during the procedure. There is an ongoing debate about which procedure is superior, so the epi-on approach may get FDA approval one day. For now though, there is generally not a way to get your insurance to cover this approach. (Learn More)

Corneal Cross-Linking

Insurance word written on wood block

Corneal cross-linking is a procedure used to treat some cases of keratoconus, a condition where the cornea, normally shaped like a dome, loses structure and becomes more coned shaped. This deformation ranges pretty widely in severity, and it can be difficult to predict how the condition will progress.

Since keratoconus affects the lens of your eye, it also affects your eye’s ability to properly take in light, worsening your vision. It also generally makes LASIK surgery too risky, as that involves cutting your already weakened cornea.

While keratoconus is generally a lifelong condition, there are treatments available to help the majority of patients. One of the available options is corneal cross-linking.

Corneal cross-linking involves the use of eye drop medication and ultraviolet (UV) light to strengthen the tissue in your cornea. While this doesn’t “fix” your sight, it can help to prevent your eye from bulging further, which can worsen your sight.

Presently, this is the only procedure known to stop progressive keratoconus. Corneal cross-linking is sometimes essential to prevent a corneal transplant, the most extreme measure in treating severe cases of keratoconus.

Costs and Insurance

Assuming one simply pays out of pocket, corneal cross-linking usually will cost somewhere between $2,500 and $4,000 per eye. Insurance will usually cover some part of that expense.

Coverage largely depends on the type of procedure performed. There are two basic types of cross-linking procedures.

  • Epithelium-off cross-linking (epi-off): In an epi-off procedure, the epithelium of the cornea is carefully removed, allowing liquid riboflavin (a medication that is important to strengthening your eye) to more easily penetrate the cornea.

    This procedure can cause mild to significant discomfort as you recover. You will need to wear special contacts during the recovery process.

  • Epithelium-on cross-linking (epi-on): This procedure does not require the removal of the epithelium. Recovery is fairly quick, and there is little to no pain as you recover.

    There is certainly evidence that this procedure has its advantages, at least under the right conditions, although its long-term efficacy is not yet fully understood. It is not superior to epi-off procedures in every way.

close up focus on an eye

The vast majority of people who have insurance should be able to have some or most of the cost of epithelium-off cross-linking covered. The procedure is FDA approved, generally considered effective, and usually considered medically necessary to treat progressive keratoconus. There is no reasonably cheaper or safer alternative available.

Epithelium-on cross-linking is generally not covered by insurance. This is primarily because this variant of the procedure is not FDA approved, making the procedure an “off-label” use of the relevant medications and procedures.

While off-label uses for medications and procedures are not inherently dangerous, as long as a medical professional is engaging in such use with reasonable cause, insurance companies will usually only cover FDA-approved uses of medications and procedures.

Many big insurance companies, such as Aetna, Cigna, Moda Health, and others, either say that they cover epithelium-off cross-linking specifically and/or mention that they do not cover epithelium-off cross-linking in their policy documentation.

These facts may understandably frustrate some as the epi-on approach is notably less invasive and less uncomfortable during the recovery process. Some experts argue, with reasonable evidence, that there is less risk of complications. At the same time, other experts argue in favor of the epi-off approach since it is backed with more evidence and has a greater chance of slowing or stopping the progression of progressive keratoconus.

Can the Epi-On Approach Be Covered by Insurance?

The reality is that virtually no insurance plan will cover the epi-on cross-linking approach to treating progressive keratoconus. While it is possible to make exemption requests, asking your insurance company to cover a procedure they would not ordinarily cover, it is extremely unlikely they will do so in this case since there is an FDA-approved alternative.

This may change in the future, as the body of evidence regarding the short-term and long-term effects of epithelium-on cross-linking grows. Most likely, FDA approval is needed for the epi-on cross-linking procedure to be covered.

References

What Is Corneal Cross-Linking? (July 2019). WebMD.

What Is Keratoconus? (September 2019). WebMD.

Corneal Cross-linking Treatment for Keratoconus. (June, 2019). All About Vision.

Is There a Cure for Keratoconus? (February, 2018). All About Vision.

Efficacy of Iontophoresis-assisted Epithelium-on Corneal Cross-Linking for Keratoconus. (April 2018). International Journal of Ophthalmology.

Corneal Collagen Crosslinking: Is Epi-Off or Epi-On Best for Patients? (September, 2017). EyeWorld News Service.

Keratoconus. (March 2019). Mayo Clinic.

Is Cross-Linking at a Crossroads? (September 2017). Review of Ophthalmology.

How to Bill for Corneal Cross-Linking. (February 2018). American Academy of Ophthalmology.

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