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Updated policies on aqueous shunts, microstents, viscocanalostomy, and canaloplasty for the treatment of glaucoma

September 5, 2018

Independence is updating our policies on aqueous shunts, microstents, viscocanalostomy, and canaloplasty for the treatment of glaucoma to reflect a change in coverage position and clarify billing requirements.

The following policies were posted as Notifications on the Medical Policy Portal on July 25, 2018, and will go into effect October 22, 2018:

  • Commercial: #11.05.16g: Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
  • Medicare Advantage: #MA11.105e: Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma

Change to coverage position

Effective October 22, 2018, the coverage position for certain uses of aqueous shunts or stents (e.g., XEN? Gel Stent), for both commercial and Medicare Advantage products, will change from Medically Necessary to Experimental/Investigational as follows:

  • The use of ab interno aqueous stents approved by the U.S. Food and Drug Administration (FDA) as a method to reduce intraocular pressure in patients with glaucoma where medical therapy has failed to adequately control intraocular pressure, is considered experimental/investigational and, therefore, not covered because the available published peer-reviewed literature does not support their use in the treatment of illness or injury.
  • The use of an ab externo aqueous shunt or ab interno aqueous stent for other conditions, including individuals with glaucoma when the intraocular pressure is controlled by medication, is considered experimental/investigational and, therefore, not covered because the available published peer-reviewed literature does not support their use in the treatment of illness or injury.
  • The use of more than one ab externo aqueous shunt or ab interno aqueous stent is considered experimental/investigational and, therefore, not covered, because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

Billing requirements

In addition, we have clarified the billing requirements within these policies. Claims submitted for implantation of microstents (CPT® code 0191T or 0474T) on or after October 22, 2018, must include a diagnosis code for mild-to-moderate open-angle glaucoma and one of the cataract diagnosis codes listed in Attachment A of the policies.

For more information

To view the Notifications for these policies, go to the Medical Policy Portal. Select Accept and Go to Medical Policy Online. Then select Commercial or Medicare Advantage under Active Notifications.

CPT Copyright 2017 American Medical Association. All rights reserved. CPT? is a registered trademark of the American Medical Association.


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