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Mitch Ibach, OD – To Pay or Not to Pay

“The tremendous efforts by clinicians, payers and our industry partners have strengthened our coverage and ability to provide this breakthrough treatment to the patients who really need it.” – Dr. Mitch Ibach, OD, Vance Thompson Vision

Image of Mitch Ibach.

Over the last several years, more and more insurance carriers have established positive coverage policies for iLink™ FDA-approved corneal cross-linking. Today, more than 95% of commercially insured patients have access to this procedure to slow or halt the progression of keratoconus. Major insurance carriers, such as Aetna and Cigna, have positive coverage policies for iLink FDA-approved cross-linking, demonstrating their belief that this procedure is medically necessary for the treatment of progressive keratoconus. However, not everyone that is part of the 95% will have full insurance coverage for iLink FDA-approved cross-linking.

In a recent Mastering Keratoconus blog post on Primary Care Optometry News, Dr. Mitch Ibach, a residency-trained optometrist at Vance Thompson Vision in Sioux Falls, South Dakota, discusses insurance coverage for iLink FDA-approved cross-linking and outlines reasons why specific cross-linking procedures may not be fully covered.

Generally, insurance carriers look to FDA-approval inclusion and exclusion criteria when determining coverage. Dr. Ibach shares three explanations as to why insurance may not cover a cross-linking procedure.

Image of people at a desk with paperwork.

  1. Patients with central corneal scars or corneal pathology that could delay healing, were excluded from approval trial and may require additional documentation to receive insurance coverage.
  2. Defined progression according to the clinical trial criteria, is often required for insurance coverage. Insurance companies may mandate documentation of specific criteria demonstrating progression of keratoconus.
  3. Non-FDA-approved procedures are not covered by insurance. Only iLink FDA-approved epithelium-off cross-linking with Photrexa® Viscous, Photrexa® and the KXL® System is eligible for insurance coverage.

Not everyone living with keratoconus has access to insurance. For patients who have no insurance, or patients with state low-income or disability health insurance benefits, such as Medicaid, there are programs available where participating practices are able to offer the iLink procedure at a reduced fee or sometimes at no cost.

Insurance coverage and treatment costs factor into any medical decision, but if left untreated, progressive keratoconus can lead to significant vision loss and the need for a corneal transplant. iLink FDA-approved cross-linking is effective in slowing or halting keratoconus, and early intervention ultimately helps preserve vision. To learn more about insurance coverage for iLink FDA-approved corneal cross-linking, read Dr. Ibach’s blog today.

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Suggestions offered by the physician are based on their experiences using the KXL® System and are their opinion. Medical decisions for your patients are to be based upon their condition and your medical judgment. The company does not recommend or endorse any particular course of treatment or medical choice.

Dr. Mitch Ibach is a paid consultant of Glaukos.

Using Photrexa® Viscous (riboflavin 5’-phosphate in 20% dextran ophthalmic solution), Photrexa® (riboflavin 5’-phosphate ophthalmic solution), and the KXL® System, the iLink™ corneal cross-linking procedure from Glaukos is the only FDA-approved therapeutic treatment for patients with progressive keratoconus and corneal ectasia following refractive surgery.*1

[Photrexa IFU/p1/col1/para3/lines1-4]

Indications

Photrexa® 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 for the treatment of progressive keratoconus and corneal ectasia following refractive surgery.

Important Safety Information

Corneal collagen cross-linking should not be performed on pregnant women.

Ulcerative keratitis can occur. Patients should be monitored for resolution of epethelial defects. The most common ocular adverse reaction was corneal opacity (haze). Other ocular side effects include punctate keratitis, corneal striae, dry eye, corneal epithelium defect, eye pain, light sensitivity, reduced visual acuity, and blurred vision.

These are not all the side effects of the corneal collagen cross-linking treatment. For more information, go www.livingwithkeratoconus.com to obtain the FDA-approved product labeling.

You are encouraged to report all side effects to the FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088.

*Photrexa® Viscous and Photrexa® are manufactured for Avedro. The KXL® System is manufactured by Avedro. Avedro is a wholly owned subsidiary of Glaukos Corporation.

Reference

1. Photrexa [package insert]. Waltham, MA: Glaukos, Inc. 2016