Aqueous Shunts and Stents for Glaucoma

Policy ID: S-236-016

Section: Surgery

Effective Date: July 01, 2019

Revised Date: December 14, 2021

Revision Effective Date: January 01, 2022

Last Reviewed: July 26, 2023

Applies To: Commercial and Medicaid Expansion

Description

Glaucoma surgery is intended to reduce intraocular pressure (IOP) when the target IOP cannot be reached with medications. Due to complications with established surgical approaches such as trabeculectomy, a variety of devices, including aqueous shunts, are being evaluated as alternative surgical treatments for patients with inadequately controlled glaucoma. Microstents are also being evaluated in individuals with mild to moderate open-angle glaucoma currently treated with ocular hypotensive medication.

Criteria

Insertion of ab externo aqueous shunts approved by the U.S. Food and Drug Administration (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

Implantation of one (1) or two (2) FDA-approved interno stents in conjunction with cataract surgery may be considered medically necessary in individuals with mild-to-moderate open-angle glaucoma treated with ocular hypotensive medication.

Use of ab interno stents 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

0253T

0474T

66175

66989

66991

Diagnosis Codes

Covered Diagnosis Codes for procedure codes 66174, 66183, 0449T, 0450T, 0671T

H40.001

H40.002

H40.003

H40.011

H40.012

H40.013

H40.021

H40.022

H40.023

H40.041

H40.042

H40.043

H40.051

H40.052

H40.053

H40.061

H40.062

H40.063

H40.10X0

H40.10X1

H40.10X2

H40.10X3

H40.10X4

H40.1110

H40.1111

H40.1112

H40.1113

H40.1114

H40.1120

H40.1121

H40.1122

H40.1123

H40.1124

H40.1130

H40.1131

H40.1132

H40.1133

H40.1134

H40.1210

H40.1211

H40.1212

H40.1213

H40.1214

H40.1220

H40.1221

H40.1222

H40.1223

H40.1224

H40.1230

H40.1231

H40.1232

H40.1233

H40.1234

H40.1310

H40.1311

H40.1312

H40.1313

H40.1314

H40.1320

H40.1321

H40.1322

H40.1323

H40.1324

H40.1330

H40.1331

H40.1332

H40.1333

H40.1334

H40.1410

H40.1411

H40.1412

H40.1413

H40.1414

H40.1420

H40.1421

H40.1422

H40.1423

H40.1424

H40.1430

H40.1431

H40.1432

H40.1433

H40.1434

H40.151

H40.152

H40.153

H40.20X0

H40.20X1

H40.20X2

H40.20X3

H40.20X4

H40.211

H40.212

H40.213

H40.2210

H40.2211

H40.2212

H40.2213

H40.2214

H40.2220

H40.2221

H40.2222

H40.2223

H40.2224

H40.2230

H40.2232

H40.2233

H40.2234

H40.231

H40.232

H40.233

H40.241

H40.242

H40.243

H40.31X0

H40.31X1

H40.31X2

H40.31X3

H40.31X4

H40.32X0

H40.32X1

H40.32X2

H40.32X3

H40.32X4

H40.33X0

H40.33X1

H40.33X2

H40.33X3

H40.33X4

H40.41X0

H40.41X1

H40.41X2

H40.41X3

H40.41X4

H40.42X0

H40.42X1

H40.42X2

H40.42X3

H40.42X4

H40.43X0

H40.43X1

H40.43X2

H40.43X3

H40.43X4

H40.51X0

H40.51X1

H40.51X2

H40.51X3

H40.51X4

H40.52X0

H40.52X1

H40.52X2

H40.52X3

H40.52X4

H40.53X0

H40.53X1

H40.53X2

H40.53X3

H40.53X4

H40.61X0

H40.61X1

H40.61X2

H40.61X3

H40.61X4

H40.62X0

H40.62X1

H40.62X2

H40.62X3

H40.62X4

H40.63X0

H40.63X1

H40.63X2

H40.63X3

H40.63X4

H40.811

H40.812

H40.813

H40.821

H40.822

H40.823

H40.831

H40.832

H40.833

H40.89

H42

Q15.0

Covered Diagnosis Codes for procedure codes 0253T, 0474T, 66175, 66989, 66991

H25.011

H25.012

H25.013

H25.019

H25.031

H25.032

H25.033

H25.039

H25.041

H25.042

H25.043

H25.049

H25.091

H25.092

H25.093

H25.099

H25.10

H25.11

H25.13

H25.811

H25.812

H25.813

H25.89

H25.9

H26.001

H26.002

H26.003

H26.009

H26.011

H26.012

H26.013

H26.019

H26.031

H26.032

H26.033

H26.039

H26.041

H26.042

H26.043

H26.049

H26.051

H26.052

H26.053

H26.059

H26.061

H26.062

H26.063

H26.069

H26.09

H26.101

H26.102

H26.103

H26.109

H26.111

H26.112

H26.113

H26.119

H26.121

H26.122

H26.123

H26.129

H26.131

H26.132

H26.133

H26.139

H26.20

H26.211

H26.212

H26.213

H26.219

H26.221

H26.222

H26.223

H26.229

H26.231

H26.232

H26.233

H26.239

H26.30

H26.31

H26.32

H26.33

H26.40

H26.411

H26.412

H26.413

H26.419

H26.491

H26.492

H26.493

H26.499

H26.8

H26.9

H40.10X0

H40.10X1

H40.10X2

H40.10X3

H40.10X4

H40.1110

H40.1111

H40.1112

H40.1113

H40.1114

H40.1120

H40.1121

H40.1122

H40.1123

H40.1124

H40.1130

H40.1131

H40.1132

H40.1133

H40.1134

H40.1210

H40.1211

H40.1212

H40.1213

H40.1214

H40.1220

H40.1221

H40.1222

H40.1223

H40.1224

H40.1230

H40.1231

H40.1232

H40.1233

H40.1234

H40.1310

H40.1311

H40.1312

H40.1313

H40.1314

H40.1320

H40.1321

H40.1322

H40.1323

H40.1324

H40.1330

H40.1331

H40.1332

H40.1333

H40.1334

H40.1410

H40.1411

H40.1412

H40.1413

H40.1414

H40.1420

H40.1421

H40.1422

H40.1423

H40.1424

H40.1430

H40.1431

H40.1432

H40.1434

H40.151

H40.152

H40.153

H40.61X0

H40.61X1

H40.61X2

H40.61X3

H40.61X4

H40.62X0

H40.62X1

H40.62X2

H40.62X3

H40.62X4

H40.63X0

H40.63X1

H40.63X2

H40.63X3

H40.63X4

H42

Q15.0

Professional Statements and Societal Positions Guidelines

American Glaucoma Society (AGS) – 2012

A position statement by the AGS indicated that new technology whose intraocular pressure (IOP)-lowering effect allows for a reduction in medications, or a reduction in the need for more advanced surgical care, or improves patient adherence to care, would provide benefits to glaucoma patients. If effective and safe, AGS suggested these benefits and the fact that these technologies would not have bleb-related complications would represent an “improvement in net health outcomes.” Also, AGS stated that some categories of new surgical devices and techniques are used at the time of concomitant cataract surgery. Because cataract surgery alone has been shown to lower IOP, a control group of patients with similar entry criteria undergoing cataract surgery alone may be appropriate for these technologies.

ND Committee Review

Internal Medical Policy Committee 1-22-2020 Revision

Differentiates between ab externo and ab interno

Internal Medical Policy Committee 3-17-2021 Annual Review- updated language

Internal Medical Policy Committee 9-21-2021 Revision

Updated criteria, and
Updated language

Internal Medical Policy Committee 11-23-2021 Coding update-Effective January 01, 2022

Added procedure code 0671T; 66991 and 66989
Removed procedure codes 0191T and 0376T

Internal Medical Policy Committee 7-21-2022 Annual Review, no changes in criteria

Internal Medical Policy Committee 7-26-2023 Annual Review, no changes in criteria

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: S-236-014

Section: Surgery

Effective Date: July 01, 2019

Revised Date: December 14, 2021

Revision Effective Date: January 01, 2022

Last Reviewed: November 23, 2021

Archived Date: July 21, 2022

Applies To: Commercial and Medicaid Expansion

Description

Criteria

Procedure Codes

66174

66183

0449T

0450T

0671T

Procedure Codes

0253T

0474T

66175

66989

66991

Diagnosis Codes

Covered Diagnosis Codes for procedure codes 66174, 66183, 0449T, 0450T, 0671T

H40.001

H40.002

H40.003

H40.011

H40.012

H40.013

H40.021

H40.022

H40.023

H40.041

H40.042

H40.043

H40.051

H40.052

H40.053

H40.061

H40.062

H40.063

H40.10X0

H40.10X1

H40.10X2

H40.10X3

H40.10X4

H40.1110

H40.1111

H40.1112

H40.1113

H40.1114

H40.1120

H40.1121

H40.1122

H40.1123

H40.1124

H40.1130

H40.1131

H40.1132

H40.1133

H40.1134

H40.1210

H40.1211

H40.1212

H40.1213

H40.1214

H40.1220

H40.1221

H40.1222

H40.1223

H40.1224

H40.1230

H40.1231

H40.1232

H40.1233

H40.1234

H40.1310

H40.1311

H40.1312

H40.1313

H40.1314

H40.1320

H40.1321

H40.1322

H40.1323

H40.1324

H40.1330

H40.1331

H40.1332

H40.1333

H40.1334

H40.1410

H40.1411

H40.1412

H40.1413

H40.1414

H40.1420

H40.1421

H40.1422

H40.1423

H40.1424

H40.1430

H40.1431

H40.1432

H40.1433

H40.1434

H40.151

H40.152

H40.153

H40.20X0

H40.20X1

H40.20X2

H40.20X3

H40.20X4

H40.211

H40.212

H40.213

H40.2210

H40.2211

H40.2212

H40.2213

H40.2214

H40.2220

H40.2221

H40.2222

H40.2223

H40.2224

H40.2230

H40.2232

H40.2233

H40.2234

H40.231

H40.232

H40.233

H40.241

H40.242

H40.243

H40.31X0

H40.31X1

H40.31X2

H40.31X3

H40.31X4

H40.32X0

H40.32X1

H40.32X2

H40.32X3

H40.32X4

H40.33X0

H40.33X1

H40.33X2

H40.33X3

H40.33X4

H40.41X0

H40.41X1

H40.41X2

H40.41X3

H40.41X4

H40.42X0

H40.42X1

H40.42X2

H40.42X3

H40.42X4

H40.43X0

H40.43X1

H40.43X2

H40.43X3

H40.43X4

H40.51X0

H40.51X1

H40.51X2

H40.51X3

H40.51X4

H40.52X0

H40.52X1

H40.52X2

H40.52X3

H40.52X4

H40.53X0

H40.53X1

H40.53X2

H40.53X3

H40.53X4

H40.61X0

H40.61X1

H40.61X2

H40.61X3

H40.61X4

H40.62X0

H40.62X1

H40.62X2

H40.62X3

H40.62X4

H40.63X0

H40.63X1

H40.63X2

H40.63X3

H40.63X4

H40.811

H40.812

H40.813

H40.821

H40.822

H40.823

H40.831

H40.832

H40.833

H40.89

H42

Q15.0

Covered Diagnosis Codes for procedure codes 0253T, 0474T, 66175, 66989, 66991

H25.011

H25.012

H25.013

H25.019

H25.031

H25.032

H25.033

H25.039

H25.041

H25.042

H25.043

H25.049

H25.091

H25.092

H25.093

H25.099

H25.10

H25.11

H25.13

H25.811

H25.812

H25.813

H25.89

H25.9

H26.001

H26.002

H26.003

H26.009

H26.011

H26.012

H26.013

H26.019

H26.031

H26.032

H26.033

H26.039

H26.041

H26.042

H26.043

H26.049

H26.051

H26.052

H26.053

H26.059

H26.061

H26.062

H26.063

H26.069

H26.09

H26.101

H26.102

H26.103

H26.109

H26.111

H26.112

H26.113

H26.119

H26.121

H26.122

H26.123

H26.129

H26.131

H26.132

H26.133

H26.139

H26.20

H26.211

H26.212

H26.213

H26.219

H26.221

H26.222

H26.223

H26.229

H26.231

H26.232

H26.233

H26.239

H26.30

H26.31

H26.32

H26.33

H26.40

H26.411

H26.412

H26.413

H26.419

H26.491

H26.492

H26.493

H26.499

H26.8

H26.9

H40.10X0

H40.10X1

H40.10X2

H40.10X3

H40.10X4

H40.1110

H40.1111

H40.1112

H40.1113

H40.1114

H40.1120

H40.1121

H40.1122

H40.1123

H40.1124

H40.1130

H40.1131

H40.1132

H40.1133

H40.1134

H40.1210

H40.1211

H40.1212

H40.1213

H40.1214

H40.1220

H40.1221

H40.1222

H40.1223

H40.1224

H40.1230

H40.1231

H40.1232

H40.1233

H40.1234

H40.1310

H40.1311

H40.1312

H40.1313

H40.1314

H40.1320

H40.1321

H40.1322

H40.1323

H40.1324

H40.1330

H40.1331

H40.1332

H40.1333

H40.1334

H40.1410

H40.1411

H40.1412

H40.1413

H40.1414

H40.1420

H40.1421

H40.1422

H40.1423

H40.1424

H40.1430

H40.1431

H40.1432

H40.1434

H40.151

H40.152

H40.153

H40.61X0

H40.61X1

H40.61X2

H40.61X3

H40.61X4

H40.62X0

H40.62X1

H40.62X2

H40.62X3

H40.62X4

H40.63X0

H40.63X1

H40.63X2

H40.63X3

H40.63X4

H42

Q15.0

Professional Statements and Societal Positions Guidelines

American Glaucoma Society (AGS) – 2012

ND Committee Review

Internal Medical Policy Committee 1-22-2020 revision differentiates between ab externo and ab interno

Internal Medical Policy Committee 3-17-2021 Annual Review- updated language

Internal Medical Policy Committee 9-21-2021 Revision-updating criteria and language

Internal Medical Policy Committee 11-23-2021 Coding update-Effective January 01, 2022

Added procedure code 0671T; 66991 and 66989
Removed procedure codes 0191T and 0376T

Links

References (PDF)

Disclaimer

Our Partners in Health:
Members
Employers
Producers

Fargo (Headquarters)
4510 13th Ave. S.
Fargo, N.D., 58121

Medical Policies Quick Search