Aqueous Shunts and Stents for Glaucoma

Section: Surgery
Effective Date: March 01, 2020
Revised Date: January 22, 2020
Last Reviewed: January 22, 2020

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 patients 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 medical therapy has 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 medical therapy has failed to adequately control intraocular pressure.

Use of ab externo or ab interno aqueous shunt(s) for all other conditions when IOP is adequately controlled by medications 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

0449T
0450T 66174 66183

Implantation of 1 or 2 FDA-approved microstents in conjunction with cataract surgery may be considered medically necessary in patients with mild to moderate open-angle glaucoma currently treated with ocular hypotensive medication. 

Use of ab interno stents for all other conditions 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

66175 0191T 0253T 0376T 0474T

Diagnosis Codes

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

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 66175, 0191T, 0253T, 0376T, 0474T

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

A position statement by the AGS (2012) 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 individual adherence to care, would provide benefits to glaucoma individuals. 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 individuals with similar entry criteria undergoing cataract surgery alone may be appropriate for these technologies.

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