MA Aqueous Shunts and Stents for Glaucoma (Preauthorization Required)
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Policy governing preauthorization, medical necessity, and coverage stance for FDA‑approved ab externo aqueous shunts and ab interno aqueous stents used to lower intraocular pressure in individuals with glaucoma; applies to Blue Cross Blue Shield - Nebraska members.
No material clinical or coverage changes in this revision.
Coverage Criteria for Aqueous Shunts and Stents
Ab externo aqueous shunts (medical necessity)
Covered when ALL of the following are met
From policy section I
Ab externo aqueous shunts (not covered)
From policy section II
Ab interno aqueous stents (standalone)
Covered when ALL of the following are met
From policy section III
Ab interno stents with cataract surgery
From policy section IV
Ab interno stents (not covered)
From policy section V
Use of ab externo or ab interno aqueous drainage devices for indications other than those specifically listed in this policy is considered outside the scope of coverage. Specifically, insertion of these devices when the member's intraocular pressure (IOP) is already adequately controlled with medical therapy is not considered reasonable and necessary. Requests for devices or procedures that do not meet the policy's stated clinical criteria (for example, situations that are not FDA‑approved indications or are not described in the coverage sections) should be expected to be denied as not medically necessary.
These Medical Policies are intended to guide benefit administration but do not constitute authorization, certification, or a contract for benefits. Coverage determinations remain subject to the specific terms and conditions of the applicable benefit contract; following this policy does not guarantee payment or authorization for a requested service.
When intraocular pressure is adequately controlled with medications, the use of an ab externo aqueous shunt is considered not reasonable and necessary and therefore not covered. By contrast, ab interno stents may be considered when used in the circumstances described in this policy (for example, implantation of 1 or 2 stents in conjunction with cataract surgery for qualifying patients); other uses of ab interno stents that fall outside the stated criteria (including non‑FDA‑approved indications) are also considered not reasonable and necessary.
Procedure and Implant Coding
| 0253T | INSERT ANT SGM DRAINAGE DEV W/O RESERVR INT APPR — Insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the suprachoroidal space |
| 0449T | INSJ AQUEOUS DRAIN DEV W/O EO RSVR INITIAL DEV — INSERTION OF AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, INTO THE SUBCONJUNCTIVAL SPACE; INITIAL DEVICE |
| 0450T | INSJ AQUEOUS DRAIN DEV W/O EO RSVR EACH ADDL DEV — INSERTION OF AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, INTO THE SUBCONJUNCTIVAL SPACE; EACH ADDITIONAL DEVICE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) |
| 0474T | INSJ ANT SEG AQUEOUS DRG DEV W/IO RSVR — INSERTION OF ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITH CREATION OF INTRAOCULAR RESERVOIR, INTERNAL APPROACH, INTO THE SUPRACILIARY SPACE |
| 0671T | INSJ ANT SGM DRG DEV TRAB MW W/O RES&CTRC RMVL1+ — Insertion of anterior segment aqueous drainage device into the trabecular meshwork, without external reservoir, and without concomitant cataract removal, one or more |
| 66179 | AQUEOUS SHUNT EXTRAOCULAR RESERVOIR W/O GRAFT — AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR, EXTERNAL APPROACH; WITHOUT GRAFT |
| 66180 | AQUEOUS SHUNT EXTRAOC EQUAT PLATE RSVR W/GRAFT — AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR, EXTERNAL APPROACH; WITH GRAFT |
| 66183 | INSERT ANTER DRAINAGE DEV W/O EXTRAOC RESERVOIR — Insertion of anterior segment aqueous drainage device, without extraocular reservoir, external approach |
| 66184 | REVJ SHUNT EXTRAOCULAR RESERVOIR W/O GRAFT — REVISION OF AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR; WITHOUT GRAFT |
| 66185 | REVJ AQUEOUS SHUNT EXTRAOCULAR RESERVOIR W/GRAFT — Revision of aqueous shunt to extraocular equatorial plate reservoir; with graft |
| CPT | Document references CPT codes; Current Procedural Terminology (CPT) is copyright American Medical Association. |
Provider Actions, Documentation, and Authorization Requirements
Preauthorization required for aqueous shunts and stents
Preauthorization is required for aqueous shunts and stents; requests must demonstrate that the indications meet the policy's medical necessity criteria (for example, failed medical therapy or specified use with cataract surgery).
- Include documentation showing that the patient meets the clinical criteria in the policy (e.g., medical therapy has failed to adequately control IOP or device is being implanted with cataract surgery where allowed).
Policy M.53: Preauthorization Required
Medical Policy M.53 is designated 'Preauthorization Required' for aqueous shunts and stents for glaucoma; obtain authorization per plan procedures before scheduling the procedure.
Prior medical therapy must have failed before standalone implantation
Policy requires documentation of prior adequate medical therapy failure before standalone surgical implantation of ab externo shunts or standalone ab interno stents, except where the policy allows stent implantation concurrently with cataract surgery.
- For standalone implantation requests, document trials of and insufficient response to ocular hypotensive medications.
Provider action: verify authorization and benefit terms
Provider awareness: follow preauthorization and documentation requirements in this policy when requesting authorization for aqueous shunt or stent procedures.
- Policies do not guarantee coverage; benefit determination is by the member's benefit contract.
Document clinical necessity and failed medical therapy
Documentation submitted with the authorization request should support that medical therapy has failed to adequately control intraocular pressure when requesting insertion of ab externo aqueous shunts or standalone ab interno stents.
- Include records of medication trials, IOP measurements, and clinical notes demonstrating inadequate control despite therapy.
Document cataract‑combined stent procedure details
When requesting implantation of 1 or 2 ab interno stents with cataract surgery, document that the patient has mild-to-moderate open‑angle glaucoma treated with ocular hypotensive medication and that cataract extraction is planned.
- Specify number of stents (1 or 2) and that the procedure is being performed in conjunction with cataract surgery.
Provider/billing reminder: follow benefit contract and coding references
Medical policies reference CPT codes and are used in administering plan benefits; follow the terms of the applicable benefit contract and plan procedures when seeking authorization and submitting claims.
- Use the CPT/HCPCS codes referenced in the policy when requesting authorization and billing.
Denial risk: ab externo shunt when IOP controlled by medication
Use of an ab externo aqueous shunt when intraocular pressure is adequately controlled by medications is considered not reasonable and necessary and may be denied.
Denial risk: ab interno stents used outside specified indications
Use of ab interno stents for conditions other than those specified (for example, not after failed medical therapy or not performed as an adjunct to cataract surgery where indicated) is considered not reasonable and necessary and may be denied.
Benefits determination reminder
Benefits for a particular service or item are determined by the terms and conditions of the applicable benefit contract; the policy does not constitute authorization or a contract for benefits and lack of benefit provision may lead to denial.
Background on Glaucoma and Device Approaches
Glaucoma is a progressive optic neuropathy typically associated with elevated intraocular pressure (IOP) due to impaired aqueous humor outflow, leading to progressive visual field loss if untreated. Surgical approaches aim to lower IOP by improving aqueous outflow and include ab externo aqueous shunts—devices implanted via an external approach to divert fluid to an external reservoir or space—and ab interno aqueous stents—intraocular implants placed via an internal approach to bypass the trabecular meshwork or access alternative outflow pathways. The policy distinguishes these approaches by indication and evidence: ab externo shunts and standalone ab interno stents may be reasonable when medical therapy has failed to adequately control IOP, while implantation of 1 or 2 ab interno stents at the time of cataract surgery is addressed separately for mild‑to‑moderate open‑angle glaucoma.
Definitions of Devices and Procedures
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