Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Policy Application
All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date
Insertion of ab externo aqueous shunts approved by the United States Food and Drug Administration (U.S. FDA) may be considered medically necessary as a method to reduce IOP in individuals with glaucoma where first-line drugs, and second-line drugs have failed to adequately control IOP.
Insertion of ab interno aqueous stents approved by the FDA may be considered medically necessary as a method to reduce IOP in individuals with glaucoma where first-line drugs, and second-line drugs have failed to adequately control IOP.
Use of ab externo or ab interno aqueous shunt(s) not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore non-covered, because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
Procedure Codes
| 66174 | 66183 | 0449T | 0450T | 0671T |
