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