Covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
Pre-operative documentation of diagnosis (e.g., OAG/POAG, OHT, refractory glaucoma) and indication for surgery (e.g., inadequate IOP control on medical therapy, need for surgical intervention).
Pre- and post-operative intraocular pressure (IOP) measurements, including medicated IOP and, where performed, unmedicated/post-washout IOP or mean diurnal IOP (many studies used medicated and post-washout IOPs and mean diurnal IOP as endpoints).
Record of number and classes of IOP-lowering medications pre- and post-procedure (primary and secondary outcomes in multiple trials include medication-free proportions and medication counts).
Documentation of prior glaucoma treatments and surgeries (e.g., prior incisional or cilio-ablative surgeries, prior laser procedures, and maximum tolerated medical therapy).
Gonioscopy findings (angle anatomy/shaffer grade) and confirmation of open angles when relevant (e.g., COMPASS generalizability to Shaffer grade ≥ 3).
Visual acuity (VA), best-corrected distance visual acuity (BCDVA), and visual field/perimetry testing (many studies recorded VA and perimetry as safety/outcome measures).
Key Coverage Criteria
Laser trabeculoplasty for treatment of members with refractory primary open-angle glaucoma (POAG) when first-line drugs (e.g., latanoprost or timolol) and second-line drugs (e.g., brimonidine or dorzolamide) have failed to control intra-ocular pressure (IOP).
FDA‑approved aqueous drainage/shunt implants for treatment of members with refractory primary open‑angle glaucoma when first-line and second-line drugs have failed to control IOP. (Examples listed in policy: Ahmed glaucoma implant; Baerveldt seton; Ex‑PRESS mini glaucoma shunt; Glaucoma pressure regulator; Krupin‑Denver valve implant; Molteno implant; Schocket shunt.)
Ab interno Kahook Dual Blade trabeculectomy — described as used for primary congenital glaucoma in case reports (Harvey and Schmitz 2020) and discussed as a minimally invasive technique.
Ab interno supraciliary microstent surgery (e.g., CyPass) — RCT evidence showed superiority combined with phacoemulsification vs phaco alone at 24 months, but long-term safety concerns (endothelial cell loss) led to device withdrawal (Cochrane review summary).
Non-penetrating deep sclerectomy (NPDS) with intra-scleral implant and adjunctive mitomycin C — used in eyes with uncontrolled glaucoma after DSAEK in small case series (Munoz-Negrete et al. 2015).
Trabeculectomy with adjunctive beta irradiation or antimetabolites — beta irradiation at time of trabeculectomy shown in trials to lower surgical failure but increase cataract risk (Cochrane review).