EmblemHealth Glaucoma Surgery Coverage Update | OpenPayer

Coverage Criteria for Glaucoma Surgery

Surgery for refractory open-angle glaucoma

Covered when ALL of the following are met

Refractory open-angle glaucoma surgery: Laser trabeculoplasty, trabeculectomy, or FDA‑approved aqueous drainage/shunt implants are medically necessary when there is intolerance, contraindication, or failure of topical/oral medications to control intraocular pressure (IOP).medication intolerance/contraindication/failure

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 for trabeculectomy.

Microstents with cataract surgery

Covered when ALL of the following are met

Microstent with cataract surgery: Insertion of the Hydrus® Microstent, iStent® Trabecular Micro-Bypass Stent system, or iStent inject® is medically necessary when performed in combination with cataract surgery for adult patients with mild to moderate open‑angle glaucoma and a cataract who are being treated with ocular hypotensive medication.mild to moderate open‑angle glaucoma; concomitant cataract surgery; on ocular hypotensive medication

XEN Glaucoma Treatment System coverage

Covered when ALL of the following are met

XEN insertion: Insertion of the XEN Glaucoma Treatment System (XEN45) is covered for management of refractory glaucoma defined as prior failure of a filtering or cilioablative procedure and/or uncontrolled IOP (progressive damage and mean diurnal medicated IOP ≥ 20 mm Hg) on maximally tolerated medical therapy (≥ 4 classes of topical IOP‑lowering medications, or fewer if tolerability/efficacy issues).prior filtering/cilioablative procedure failure and/or mean diurnal medicated IOP ≥ 20 mm Hg on maximally tolerated therapy

Must be performed by an ophthalmologist experienced with trabeculectomy and bleb management.

iStent infinite coverage

Covered when ALL of the following are met

iStent infinite: Insertion of the iStent infinite® Trabecular Micro-Bypass System (Model iS3) is medically necessary for adult patients with primary open‑angle glaucoma in whom previous medical and surgical treatment has failed.previous medical and surgical treatment failure

Adjunctive anti-fibrotic agents for Ex-PRESS

Covered when ALL of the following are met

Adjunctive use of anti-fibrotic agents: Adjunctive use of anti‑fibrotic agents (for example, mitomycin C) is medically necessary when used with the Ex‑PRESS® Glaucoma Filtration Device.use in conjunction with Ex‑PRESS device

Adjunctive anti‑fibrotic agents with other shunt/implant devices are excluded (see policy exclusions).

The policy explicitly lists several procedures as not considered medically necessary because evidence of therapeutic benefit is insufficient. These include transciliary filtration techniques (for example, Fugo Blade transciliary filtration), and ab interno trabeculectomy (trabectome) identified by CPTs 0621T and 0622T. The policy also names motorized ab interno trephination of sclera or trabecular meshwork (CPT 1012T, effective 1/1/2026) among excluded approaches, and notes additional exclusions such as beta radiation, non‑FDA approved internal glaucoma drainage devices (e.g., Eyepass™, DeepLight®), adjunctive anti‑fibrotic agents or systemic corticosteroids used with shunt implants other than the Ex‑PRESS device, and drug‑eluting lacrimal canaliculus implants (CPTs 0356T, 0444T, and 0445T).

Requests for trabeculoplasty when the indication is ocular hypertension are not automatically covered; they will be evaluated on a case‑by‑case basis. Such review requires documentation that pharmaceutical management has failed or is not tolerated. The revision history also documents prior additions of case‑by‑case language for trabeculoplasty, reinforcing that individual clinical details and submitted evidence determine medical necessity determinations.

The policy’s revision history records operational updates to CPT coverage status; items or CPT codes explicitly designated as investigational in the revision history are treated as investigational for coverage purposes. For example, CPT 1012T was added as investigational in the Nov. 14, 2025 revision entry.

The following procedures and device uses are explicitly listed in the policy as not medically necessary / unsupported by adequate evidence: ab interno trabeculectomy (trabectome, CPT 0621T/0622T); motorized ab interno trephination of sclera or trabecular meshwork (CPT 1012T effective 1/1/2026); transciliary filtration procedures (e.g., Fugo Blade transciliary filtration); beta radiation; non‑FDA approved internal glaucoma drainage devices (for example Eyepass™, DeepLight®); adjunctive anti‑fibrotic agents or systemic corticosteroids used with shunt implants other than the Ex‑PRESS device; and drug‑eluting lacrimal canaliculus implants (CPTs 0356T, 0444T, 0445T), including procedures for punctal dilation and implant removal when performed.

Operationally, any procedure or device that the revision history newly designates as investigational or not covered will be treated as not medically necessary for claims and authorization purposes. The Nov. 14, 2025 revision specifically documents that CPT 1012T was added as investigational; such items are handled as investigational per the revision history and therefore are considered not medically necessary under this policy.

Procedure, Supply, and Diagnosis Codes

Procedure and supply codesmixed

0449T	Insertion of aqueous drainage device, without extraocular reservoir, internal approach, into the subconjunctival space; initial device
0450T	Insertion of aqueous drainage device, without extraocular reservoir, internal approach, into the subconjunctival space; each additional device
0671T	Insertion of anterior segment aqueous drainage device into the trabecular meshwork, without external reservoir, and without concomitant cataract removal, one or more
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

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Not considered medically necessary / insufficient evidenceCPTNot Covered

0621T	Ab interno trabeculectomy (trabectome) (listed as not considered medically necessary)
0622T	Ab interno trabeculectomy (trabectome) (listed as not considered medically necessary)
1012T	Motorized ab interno trephination of sclera or trabecular meshwork (listed as not considered medically necessary; CPT 1012T eff. 1/1/2026)
0356T	Drug-eluting implants inserted into the lacrimal canaliculus (listed as not considered medically necessary)
0444T	Drug-eluting implants inserted into the lacrimal canaliculus (listed as not considered medically necessary)
0445T	Drug-eluting implants inserted into the lacrimal canaliculus (listed as not considered medically necessary)

ICD-10 Diagnoses (partial list)ICD-10

H25.10	Age-related nuclear cataract, unspecified eye
H25.11	Age-related nuclear cataract, right eye
H25.12	Age-related nuclear cataract, left eye
H25.13	Age-related nuclear cataract, bilateral
H40.10X1	Unspecified open-angle glaucoma, mild stage
H40.1111	Primary open-angle glaucoma, right eye, mild stage
H40.1112	Primary open-angle glaucoma, right eye, moderate stage
H40.1113	Primary open-angle glaucoma, right eye, severe stage

Covered ICD-10 Diagnosis CodesICD-10

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
H40.1213	Low-tension glaucoma, right eye, severe stage
H40.1214	Low-tension glaucoma, right eye, indeterminate stage
H40.1221	Low-tension glaucoma, left eye, mild stage
H40.1222	Low-tension glaucoma, left eye, moderate stage

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Procedure/CPT status updatesCPT

0450T	CPT - Device/procedure code (listed as added covered in revision history)
1012T	CPT - Device/procedure code (listed as added investigational in revision history)

Referenced procedure codes (non-exhaustive in this window)mixed

other MIGS/implant CPTs

Multiple MIGS and implant CPT codes referenced across document and revision history (specific list present elsewhere in policy).

Refractory glaucoma definition for XEN

Clinical definitionRefractory glaucoma for XEN: prior failure of a filtering or cilioablative procedure and/or progressive optic nerve damage with mean diurnal medicated IOP ≥ 20 mm Hg despite maximally tolerated medical therapy

Medication trial requirementMaximally tolerated medical therapy defined as use of ≥ 4 classes of topical IOP‑lowering medications (or fewer if tolerability/efficacy issues)

Procedure scopeXEN insertion must be performed by an ophthalmologist experienced with trabeculectomy and bleb management

ICD-10 specificity

Use specific codesUse the specific H40.* ICD‑10 code that matches the glaucoma type, laterality, and stage as listed in the policy (e.g., H40.1111 for POAG right eye mild)

Provider Requirements, Prior Authorization & Documentation

Prior Authorization

Submit clinical evidence for preauthorization review

Preauthorization requests must include clinical evidence that the member meets the policy criteria; without this documentation EmblemHealth cannot properly review preauthorization or post‑payment requests.

Prior Authorization

Confirm prior authorization for updated device CPT codes (0450T, 1012T)

Verify and obtain prior authorization as required for device CPT codes affected by the recent revision history—specifically confirm coverage/authorization requirements for CPT 0450T (added as covered) and CPT 1012T (added as investigational) before billing.

Background and Clinical Context

Glaucoma refers to a group of eye diseases characterized by damage to the optic nerve and progressive loss of visual field, commonly associated with elevated intraocular pressure (IOP). Management aims to lower IOP and preserve optic nerve function using topical or systemic medications, laser procedures, and surgical options that create alternate outflow pathways for aqueous humor. Surgical approaches range from traditional guarded filtration surgery (trabeculectomy) and aqueous shunt implants for refractory or advanced disease to micro‑invasive glaucoma surgeries (MIGS) and ab interno stents used to reduce IOP with less tissue disruption. Severity is typically categorized as mild, moderate, or severe based on optic nerve and visual field findings, and treatment selection depends on disease stage, prior treatment response, and tolerability of medical therapy.

Device and Procedure Definitions

Aqueous shunts / drainage devices

DefinitionAqueous shunts (aka aqueous drainage devices, glaucoma drainage devices, setons, tube implants, tube shunts) are implanted devices that create an alternate pathway to divert aqueous humor from the anterior or posterior chamber to a subconjunctival/sub‑scleral space to lower IOP

Device characteristicsDevices differ by plate size, shape, thickness, presence/absence of valve, and surgical approach

Clinical comparisonGenerally carry lower hypotony risk than trabeculectomy but may yield higher postoperative IOP compared with guarded filtration surgery

Trabeculectomy

DefinitionTrabeculectomy is a surgical filtration procedure removing part of the trabecular meshwork through a superficial scleral flap to create a subconjunctival bleb for aqueous outflow and lower IOP

Clinical role