Generally, insurance does not typically cover products and procedures that have not received FDA approval. The only FDA-approved products for cross-linking are from Avedro, and performed epi-off. Many insurance policies have detail about the fact that the epi-off procedure is the only FDA approved treatment for progressive keratoconus that is being covered, while epi-on is not. See the examples below from Aetna and Blue Cross Blue Shield of MA.
“Aetna considers epithelium-off photochemical collagen cross-linkage using riboflavin and ultraviolet A medically necessary for keratoconus and keratectasia.
Aetna considers epithelium-on (transepithelial) collagen cross-linkage experimental and investigational for keratoconus, keratectasia, and all other indications.”
“Currently, the only CXL treatment approved by the Food and Drug Administration (FDA) is the epithelium-off method. There are no FDA-approved CXL treatments using the epithelium-on method.”