By Counterforce Health Team in iLink® (corneal cross-linking system) —

How to Get iLink® Corneal Cross-Linking Covered by Blue Cross Blue Shield in New York: Prior Authorization Forms, Appeals Process, and Success Strategies

Quick Answer: Getting iLink® Covered by BCBS in New York

Blue Cross Blue Shield plans in New York generally cover FDA-approved epithelium-off iLink® corneal cross-linking for progressive keratoconus when medical necessity criteria are met. Submit prior authorization through Availity (most plans) with documented progression evidence. If denied, New York's external appeal process through DFS has strong overturn rates for properly documented cases.

First step today: Call the number on your BCBS card to confirm your exact plan type and PA requirements, then gather serial topography showing progression.

Table of Contents

BCBS Plan Types in New York

New York has several distinct Blue Cross Blue Shield entities, each with different PA requirements:

  • Empire BlueCross BlueShield (commercial and Exchange plans)
  • Excellus BlueCross BlueShield (upstate New York)
  • Highmark BCBS (Western and Northeastern NY)
  • BCBS Federal Employee Program (FEP Blue)
Important: Your ID card will show which entity administers your plan. Each has different portals and submission processes for corneal cross-linking authorization.

Network and Referral Implications

Most BCBS plans in New York operate as PPO or EPO products, meaning:

  • No referral required for ophthalmology specialist visits
  • In-network benefits apply when using participating corneal specialists
  • Prior authorization still required for iLink® regardless of network status

Coverage Requirements & Medical Necessity

What BCBS New York Plans Typically Cover

BCBS policies across New York generally cover epithelium-off corneal collagen cross-linking using the FDA-approved iLink® system when ALL criteria are met:

Requirement Specific Criteria Documentation Needed
Diagnosis Progressive keratoconus OR post-refractive ectasia ICD-10 codes H18.60-H18.69
Progression ≥1.0 D increase in Kmax over 12-24 months Serial topography reports
Age Usually ≥14-18 years (varies by plan) Date of birth verification
Corneal Thickness ≥300-400 μm after epithelial removal Pachymetry measurements
Protocol FDA-approved epi-off technique only Surgeon attestation

What's NOT Covered

  • Epithelium-on (epi-on) cross-linking - considered investigational
  • Non-FDA approved devices or protocols
  • Stable keratoconus without documented progression
  • Bilateral simultaneous treatment (most plans require separate authorizations)
Note: New York DFS external appeal decisions have established specific progression criteria that align with these requirements.

Prior Authorization Process

Submission Portals by Plan Type

Empire/Anthem BCBS Plans:

  • Submit through Availity Essentials using the Interactive Care Reviewer (ICR) tool
  • Upload supporting documents directly in the portal

Excellus BCBS:

Highmark BCBS:

Required Documentation Checklist

✅ Clinical History:

  • Comprehensive eye exam notes
  • Visual acuity measurements (both eyes)
  • Best-corrected visual acuity with current prescription

✅ Objective Progression Evidence:

  • Serial corneal topography (minimum 6-12 months apart)
  • Kmax values with dates showing ≥1.0 D increase
  • Pachymetry readings confirming adequate thickness
  • Manifest refraction changes

✅ Treatment History:

  • Documentation of spectacle/contact lens trials
  • Any previous corneal procedures
  • Failure or intolerance of conservative management

✅ Procedure Details:

  • Confirmation of FDA-approved epi-off iLink® protocol
  • Eye(s) to be treated
  • Planned site of service (office vs. ASC)
  • CPT code 0402T and HCPCS J2787

Common Denial Reasons & Solutions

Denial Reason Solution Strategy Key Documents
Insufficient progression Provide additional topography with clear Kmax progression Serial corneal maps, quantified changes
Experimental/investigational Emphasize FDA approval of epi-off iLink® FDA approval documentation
Missing medical necessity Submit comprehensive physician letter Detailed clinical rationale, literature support
Non-participating provider Request network exception or find in-network specialist Provider directory, exception request form

Strengthening Your Appeal

When Counterforce Health analyzes corneal cross-linking denials, the most successful appeals include:

  • Quantified progression metrics that match the plan's specific criteria
  • Clear articulation of vision-threatening risk without treatment
  • Evidence that CXL is the only FDA-approved treatment to halt progression
  • Cost-effectiveness arguments comparing CXL to eventual corneal transplant

New York Appeals Process

New York offers robust appeal rights through the Department of Financial Services (DFS), with particularly strong protections for "experimental/investigational" denials.

Internal Appeal (Required First Step)

Timeline: Must file within 180 days of denial (commercial plans) Process: Submit written appeal to BCBS with additional clinical evidence Decision time: 30 days (15 days for expedited)

External Appeal Through DFS

Eligibility: After receiving Final Adverse Determination from BCBS Timeline: File within 45 days of final denial Cost: Maximum $25 (waived for financial hardship) Decision: Binding on the insurer

Success Factor: DFS external appeals have overturned keratoconus denials when progression criteria are clearly documented and FDA approval is emphasized.

Expedited Appeals

Available when vision is at serious risk from rapid progression:

  • Internal expedited: 72 hours
  • External expedited: 72 hours (24 hours for urgent drug denials)

Step-by-Step Approval Guide

1. Verify Coverage and Plan Type

Who: Patient or clinic staff
Action: Call member services number on insurance card
Ask: "Is CPT 0402T with J2787 covered for progressive keratoconus? Is prior authorization required?"
Timeline: Same day

2. Gather Progression Documentation

Who: Treating ophthalmologist
Action: Compile serial topography, pachymetry, and visual acuity records
Key: Ensure ≥6 months between measurements showing clear worsening
Timeline: May require scheduling additional testing

3. Submit Prior Authorization

Who: Provider office
Portal: Availity (most plans) or plan-specific portal
Include: Complete clinical package with progression evidence
Timeline: Submit 5-7 business days before planned procedure

4. Track Authorization Status

Who: Provider office
Method: Same portal used for submission
Response time: 3-5 business days for standard, 72 hours for expedited
Follow-up: Call if no response within expected timeframe

5. If Denied, File Internal Appeal

Who: Provider with patient consent
Method: Written appeal with additional evidence
Focus: Address specific denial reason with targeted documentation
Timeline: Within 180 days of denial

6. External Appeal if Necessary

Who: Patient or provider
Method: DFS external appeal form
Include: All clinical records, physician letter, peer-reviewed literature
Timeline: Within 45 days of Final Adverse Determination

7. Schedule Treatment

Who: Provider office
Action: Confirm authorization details, patient cost-sharing
Verify: Authorization number, covered eye(s), any restrictions
Timeline: After approval received

Cost-Sharing Considerations

iLink® corneal cross-linking is typically billed as an outpatient surgical procedure, subject to:

  • Deductible: May apply if not met for the year
  • Coinsurance: Usually 10-20% for in-network specialists
  • Facility fees: Separate charges for ASC or hospital outpatient
  • Drug costs: J2787 (riboflavin) may have separate cost-sharing
Financial Planning: Total out-of-pocket costs commonly range from $500-$1,500 per eye for commercially insured patients, depending on deductible and coinsurance.

When to Escalate

Contact New York Department of Financial Services if:

  • BCBS fails to respond to PA requests within required timeframes
  • Internal appeals are improperly processed or delayed
  • You need assistance with external appeal filing
  • Plan violates New York insurance laws or regulations

Consumer Assistance: Community Health Advocates at 888-614-5400 provides free help with insurance appeals for New York residents.

FAQ

How long does BCBS prior authorization take in New York?
Standard PA decisions: 3-5 business days. Expedited (when vision at risk): 72 hours. Use expedited process if progression is rapid or surgery is scheduled soon.

What if iLink® is considered experimental by my BCBS plan?
Emphasize FDA approval for epi-off technique. If denied, file external appeal through DFS citing FDA approval and established medical literature supporting CXL for progressive keratoconus.

Can I get bilateral treatment approved?
Most BCBS plans require separate authorizations for each eye. Submit documentation showing progression in both eyes with separate PA requests.

Does step therapy apply before CXL approval?
Generally no. CXL is considered first-line treatment to halt progression. Document that spectacles/contacts don't address disease progression, only vision correction.

What if my surgeon isn't in the BCBS network?
Request a network exception by demonstrating no qualified in-network corneal specialists are available within reasonable distance. Include provider credentials and patient travel burden.

How do I expedite approval for rapidly progressing keratoconus?
Document rapid Kmax changes (>1D in <6 months), submit expedited PA with urgent clinical justification, and emphasize vision-threatening progression requiring immediate intervention.

From our advocates: "We've seen the strongest CXL approvals when the ophthalmologist's letter specifically quantifies progression using the exact metrics BCBS policies reference - like '2.1 D Kmax increase over 8 months' rather than general statements about worsening. The numbers make the medical necessity undeniable."

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. Our platform analyzes denial letters and plan policies to create targeted, evidence-backed appeals that align with each payer's specific requirements. For complex cases like corneal cross-linking, we identify the precise clinical criteria and craft point-by-point rebuttals using FDA labeling, peer-reviewed studies, and plan-specific language that maximizes approval chances.

Sources & Further Reading

Medical Disclaimer: This information is for educational purposes only and does not constitute medical advice. Coverage decisions depend on individual plan benefits and medical circumstances. Always verify current policy terms with your insurance carrier and consult your healthcare provider for medical guidance regarding keratoconus treatment options.

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