EmblemHealth Glaucoma Surgery Coverage Update

Coverage Criteria for Glaucoma Surgical Interventions

Indications for laser, trabeculectomy, and shunt implants

Covered when ALL of the following are met

General surgical indication: Laser trabeculoplasty, trabeculectomy or FDA-approved aqueous drainage/shunt implants are medically necessary for the treatment of refractory open-angle glaucoma when there is intolerance, contraindication or failure of topical/oral medication to control IOP.

Goniotomy requests will be reviewed on a case-by-case basis; antimetabolites such as 5-Fluorouracil (5-FU) may be considered medically necessary to inhibit wound healing.

Microstent (iStent/iStent inject/Hydrus) coverage

Covered when ALL of the following are met

Microstent with cataract surgery: One iStent, iStent inject or Hydrus Microstent per eye is considered medically necessary when used in combination with cataract surgery for mild to moderate open-angle glaucoma in adult members who are being treated with ocular hypotensive medication and have a cataract.

XEN4S device coverage

Covered when ALL of the following are met

XEN4S for refractory glaucoma: One XEN4S device per eye is covered for the management of refractory glaucoma defined as failure of a filtering/cilioablative procedure and/or uncontrolled IOP (progressive damage and mean diurnal medicated IOP >= 20 mm Hg) on maximally tolerated medical therapy.mean diurnal medicated IOP \u003e\u003d 20 mm Hg

Insertion must be performed by an ophthalmologist with experience in trabeculectomy and bleb management.

iStent infinite coverage

Covered when ALL of the following are met

iStent infinite: One iStent infinite Trabecular Micro-Bypass System (Model iS3) per eye is considered medically necessary for adult patients with primary open-angle glaucoma in whom previous medical and surgical treatment has failed.

This indication was added to coverage in the revision history.

Anti-fibrotic adjunctive therapy

Covered when ALL of the following are met

Anti-fibrotic with Ex-PRESS: Adjunctive use of anti-fibrotic agents (for example, mitomycin C) is considered medically necessary when used with the Ex-PRESS mini glaucoma shunt.

Adjunctive mitomycin C with other shunt implants is specifically noted elsewhere and antimetabolites such as 5-FU may be considered to inhibit wound healing; adjunctive use with other implants may be limited per exclusions.

Device coverage and review notes

Coverage stance based on device history and diagnosis coding

Device coverage history: Specific MIGS devices (including iStent infinite, Hydrus, XEN4S, and historic CyPass coverage) are referenced in the policy revision history; CyPass was later removed following an Alcon recall. Some device indications were added over time and may be subject to case-by-case review.

No additional explicit eligibility criteria are provided in these revision/history notes; refer to specific device criteria above.

Diagnosis coding: Appropriate ICD-10 glaucoma diagnosis codes (for example, H40.* series) must be used on claims and are enumerated in the policy's coding section.

See ICD-10 Covered Diagnosis Codes for full list.

The policy lists several procedures and devices that are not considered medically necessary because of insufficient evidence of therapeutic value. These include transciliary filtration procedures (for example, the Fugo Blade), ab interno trabeculectomy (trabectome; CPT 0621T, 0622T), and beta radiation. Also excluded are glaucoma drainage devices without FDA approval (for example Eyepass and DeepLight SOLX Gold Shunt), the adjunctive use of anti-fibrotic agents or systemic corticosteroids with shunt implants other than the Ex-PRESS mini shunt, and drug-eluting lacrimal canaliculus implants (including CPT 0356T, 0444T, 0445T and associated punctal dilation/implant removal) for glaucoma or ocular hypertension.

Requests for trabeculoplasty to treat ocular hypertension are not automatically approved; instead they will be reviewed on a case-by-case basis for members who have failed pharmaceutical management. The revision history documents the addition of this case-by-case review language, underscoring that clinical evidence of failed medication management should be submitted for evaluation.

The policy notes a historical change relating to the CyPass microstent: although CyPass coverage was previously added, it was later removed as a covered device due to the Alcon recall in August 2018. Providers should not submit claims for CyPass following removal from coverage and should consult the revision history for recall-related guidance.

The document explicitly states that the procedures and devices enumerated in the Limitations/Exclusions section are not considered medically necessary due to insufficient evidence of therapeutic value. Providers should refer to that exclusions list when evaluating requests for coverage of these specific techniques or implants.

Although the policy includes statements that certain devices were removed from coverage (for example CyPass) and records additions to device indications in the revision history, there are no additional explicit ‘not medically necessary’ statements

Procedure, Supply, and Diagnosis Codes

Procedure Codes (implant insertion)CPTCovered

0449T	Insertion of aqueous drainage device, without extraocular reservoir, internal approach, into the subconjunctival space; initial device.
0671T	Insertion of anterior segment aqueous drainage device into the trabecular meshwork, without external reservoir, and without concomitant cataract removal; one or more.

Procedure Codes (trabeculectomy, shunts, cyclodestruction, cataract with device)CPTCovered

65855	Trabeculoplasty by laser surgery.
66150	Fistulization of sclera for glaucoma; trephination with iridectomy.
66155	Fistulization of sclera for glaucoma; thermocauterization with iridectomy.
66160	Fistulization of sclera for glaucoma; sclerectomy with punch or scissors, with iridectomy.
66180	Aqueous shunt to extraocular equatorial plate reservoir, external approach; with graft.
66183	Insertion of anterior segment aqueous drainage device, without extraocular reservoir, external approach.
66184	Revision of aqueous shunt to extraocular equatorial plate reservoir; without graft.
66185	Revision of aqueous shunt to extraocular equatorial plate reservoir; with graft.
66710	Ciliary body destruction; cyclophotocoagulation, transscleral.
66720	Ciliary body destruction; cryotherapy.

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Drug/Supply CodesCPT | HCPCS

J0171	Injection, Adrenalin, epinephrine, 0.1 mg.
J1120	Injection, acetazolamide sodium, up to 500 mg.
J7315	Mitomycin, opthalmic, 0.2 mg.
L8612	Aqueous shunt

ICD-10 Diagnoses (selected samples — full list in document)ICD-10

H25.10	Age-related nuclear cataract, unspecified eye.
H40.051	Ocular hypertension, right eye.
H40.1111	Primary open-angle glaucoma, right eye, mild stage.
H40.1122	Primary open-angle glaucoma, left eye, moderate stage.
H40.1211	Low-tension glaucoma, right eye, mild stage.

ICD-10 Covered Diagnosis CodesICD-10Covered

H40.1123	Primary open-angle glaucoma, left eye, severe stage.
H40.1124	Primary open-angle glaucoma, left eye, indeterminate stage.
H40.1131	Primary open-angle glaucoma, bilateral, mild stage.
H40.1132	Primary open-angle glaucoma, bilateral, moderate stage.
H40.1133	Primary open-angle glaucoma, bilateral, severe stage.
H40.1134	Primary open-angle glaucoma, bilateral, indeterminate stage.
H40.1191	Primary open-angle glaucoma, unspecified eye, mild stage.
H40.1192	Primary open-angle glaucoma, unspecified eye, moderate stage.
H40.1211	Low-tension glaucoma, right eye, mild stage.
H40.1212	Low-tension glaucoma, right eye, moderate stage.

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Definition of refractory glaucoma for XEN4S coverage

Refractory glaucoma definitionFailure of a prior filtering or cilioablative procedure and/or uncontrolled intraocular pressure (progressive optic nerve damage) with mean diurnal medicated IOP ≥ 20 mm Hg on maximally tolerated medical therapy.

Prior procedure failureIncludes inadequate IOP control after prior filtering (e.g., trabeculectomy) or cilioablative procedures.

IOP thresholdMean diurnal medicated intraocular pressure ≥ 20 mm Hg despite maximally tolerated medical therapy.

Evidence of progressive damageProgressive optic nerve/visual field damage despite medical therapy is part of the refractory definition.

Therapy contextMaximally tolerated medical therapy may include up to multiple topical IOP‑lowering medication classes; fewer may be acceptable if limited by tolerability or efficacy.

Preauthorization, Documentation, and Submission Requirements

Prior Authorization
Prior Authorization / Case-by-Case Review
Prior authorization or case-by-case review may be required for certain glaucoma devices and procedures. Providers should request preauthorization when submitting for devices such as iStent infinite, Hydrus, XEN4S (historical coverage may require review), and for procedures where policy text indicates case-by-case review (for example, goniotomy or selected trabeculoplasty requests).
Affected devices/procedures: iStent infinite, iStent inject, Hydrus Microstent, XEN4S (historical), goniotomy (case-by-case), trabeculoplasty (case-by-case)

Documentation Required
Documentation Requirement for Review
The treating physician or primary care provider must submit all relevant clinical documentation to EmblemHealth to support the medical necessity of the requested treatment or surgical procedure. Without this documentation EmblemHealth will not be able to properly review preauthorization requests or perform post-payment review, which may delay or result in denial of coverage.

Clinical Background

Glaucoma represents a group of eye diseases characterized by progressive optic nerve damage and potential vision loss related to elevated or improperly regulated intraocular pressure (IOP). In open-angle glaucoma, impaired aqueous humor outflow leads to increased IOP despite an open anterior chamber angle; treatment strategies (topical or systemic medications, laser procedures, or surgical drainage interventions) all aim to lower IOP to prevent further optic nerve injury and visual field loss.

Procedural and Device Definitions

Aqueous shunts / microstents — definitions

Aqueous shunts (tube shunts)Implanted devices that create an alternate outflow pathway from the anterior/posterior chamber to the subconjunctival space to lower IOP; vary by plate size, valve presence, and surgical approach.

Microstents (e.g., iStent, Hydrus)Minimally penetrating ab interno implants placed into Schlemm's canal or the suprachoroidal space to enhance physiologic outflow; often inserted at the time of cataract surgery.

Ab interno advantageMicrostents can be implanted through the same incision used for cataract surgery and typically do not preclude later trabeculectomy if needed.

Comparative risk/outcome noteAqueous shunts generally reduce the risk of hypotony compared with trabeculectomy but may yield higher long‑term IOP than guarded filtration surgery.

Trabeculectomy — definition

Document Revisions and Change Log

2025-03-14administrativeLatest

Transferred policy content to individual company branded template.

2023-04-14coverage_change

Added iStent infinite indication.

2020-09-11clinical_note

Added a note pertaining to trabeculectomy regarding prophylactic use of 5‑Fluorouracil (5‑FU).