Amniotic membrane therapy is generally considered when there is objective evidence of significant ocular-surface injury, impaired epithelial healing, inflammation, ulceration, or risk of additional tissue damage.
It is important for patients to understand that a clinical recommendation and an insurance company’s definition of medical necessity are not necessarily identical. Coverage criteria vary between Medicare and commercial insurance plans.
Common diagnoses and clinical conditions for which amniotic membrane therapy may be considered include:
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Persistent corneal epithelial defect / non-healing epithelial defect
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Neurotrophic keratitis
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Neurotrophic corneal ulcer
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Severe epithelial breakdown associated with ocular surface disease
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Chemical injury or chemical burn of the ocular surface
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Thermal injury to the ocular surface
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Corneal ulcer with persistent epithelial defect after appropriate management of infection
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Corneal stromal thinning or corneal melt
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Severe punctate keratitis with significant epithelial compromise in selected cases
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Limbal stem-cell deficiency
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Stevens-Johnson syndrome and other severe cicatrizing ocular-surface disorders
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Bullous keratopathy with epithelial compromise
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Peripheral ulcerative keratitis in selected cases
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Severe exposure keratopathy
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Recurrent corneal erosion in selected refractory cases
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Epithelial basement membrane dystrophy with recurrent epithelial breakdown in selected cases
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Filamentary keratitis associated with significant ocular-surface disease
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Ocular-surface reconstruction following significant tissue injury or surgery
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Conjunctival defects requiring reconstruction
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Symblepharon and selected conjunctival scarring disorders
The presence of a diagnosis does not automatically establish insurance coverage. Medical necessity is determined from the complete clinical picture, including severity, objective examination findings, previous treatments, response to therapy, duration of disease, and the patient’s individual insurance policy.
Insurance Coverage and Medical Necessity: Amniotic membrane treatment may be covered by Medicare or commercial insurance when applicable medical-necessity requirements are satisfied. Coverage varies according to diagnosis, severity of disease, objective clinical findings, previous treatments, individual insurance benefits, and payer policy. Prior authorization or verification of benefits does not guarantee payment. When possible, our office will review applicable benefits and expected patient financial responsibility before treatment.