CurrentExcellus Health Plan IncPolicy 9.01.18

Aqueous Drainage Devices (Stents and Shunts) for Glaucoma

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Coverage of FDA-approved aqueous drainage devices, including shunts and micro-stents, for patients with glaucoma, including medically appropriate indications, investigational uses, and micro-stent criteria when performed with cataract surgery.

Policy Summary

PayerExcellus Health Plan Inc

PolicyAqueous Drainage Devices (Stents and Shunts) for Glaucoma

Policy CodePolicy 9.01.18

Change TypeAnnual reviewtitle revised

Effective DateJanuary 22, 2026

Next Review DateJanuary 1, 2027

Key ActionConfirm that the member’s specific product covers the requested service before applying the medical policy criteria.

SourceLink

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CurrentExcellus Health Plan IncPolicy 9.01.18

Aqueous Drainage Devices (Stents and Shunts) for Glaucoma

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Sign up for excellus_health_plan_inc Policy 9.01.18 alerts

Get alerted when Policy 9.01.18 changes without checking for updates manually.

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Policy Summary

PayerExcellus Health Plan Inc

PolicyAqueous Drainage Devices (Stents and Shunts) for Glaucoma

Policy CodePolicy 9.01.18

Change TypeAnnual reviewtitle revised

Effective DateJanuary 22, 2026

Next Review DateJanuary 1, 2027

Key ActionConfirm that the member’s specific product covers the requested service before applying the medical policy criteria.

SourceLink

POLICY UPDATE CHANGES

The policy title was changed during the January 22, 2026 annual review.

FDA-approvedFDA-approved devices eligible for coverage consideration

1 or 2Micro-stents allowed with cataract surgery when criteria are met

Mild-to-moderate OAGRequired glaucoma severity for covered micro-stent implantation

InvestigationalSuprachoroidal, supraciliary, and other non-qualifying uses

Intent unchanged2026 annual review outcome

Coverage Criteria

FDA-approved aqueous drainage device

Covered as medically appropriate when the patient has glaucoma and meets either of the following indications:

Either qualifying indication

Medical therapy has failed to adequately control the intraocular pressure (IOP).
Oral or topical medications are not tolerated by the patient, such as significant gastrointestinal effects from oral medications or contact sensitivity or systemic effects from topical medications.

Micro-stent implantation with cataract surgery

Covered as medically appropriate when ALL of the following criteria are met:

All required criteria

Implantation of one or two FDA-approved micro-stents, such as iStent or iStent Inject, is performed in conjunction with cataract surgery.1 or 2 micro-stents
The patient has diagnosed mild-to-moderate open-angle glaucoma (OAG).Mild-to-moderate OAG
The patient is currently being treated with ocular hypotensive medication(s).

Aqueous drainage devices inserted into the suprachoroidal space or supraciliary space in patients with glaucoma are considered investigational.

All other uses of aqueous drainage devices are considered investigational, including use in patients with glaucoma when intraocular pressure (IOP) is adequately controlled by medications.

The CyPass Micro-Stent was voluntarily recalled and withdrawn from the global market in 2018 after long-term follow-up demonstrated a clinically and statistically significant increase in corneal endothelial cell loss. Following its review, the FDA issued a safety communication recommending that use be discontinued; the device is no longer available for use.

Billing and Diagnosis Codes

CPT CodesCPT

0253T	Insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the suprachoroidal space.
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 (List separately in addition to code for primary procedure).

CPT CodesCPT

0474T	Insertion of anterior segment aqueous drainage device, with creation of intraocular reservoir, internal approach, into the supraciliary space.
0671T	Insertion of anterior segment aqueous drainage device into the trabecular meshwork, without external reservoir, and without concomitant cataract removal, one or more.
66185	Revision of aqueous shunt to extraocular equatorial plate reservoir; with graft.
66989	Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (e.g., iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; with insertion of intraocular (e.g., trabecular meshwork, supraciliary, suprachoroidal) anterior segment aqueous drainage device, without extraocular reservoir, internal approach, one or more.

CPT CodesCPT

0253T	Insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the suprachoroidal space.
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. List separately in addition to code for primary procedure.
0474T	Insertion of anterior segment aqueous drainage device, with creation of intraocular reservoir, internal approach, into the supraciliary space.
0671T	Insertion of anterior segment aqueous drainage device into the trabecular meshwork, without external reservoir, and without concomitant cataract removal, one or more.
66185	Revision of aqueous shunt to extraocular equatorial plate reservoir; without graft; with graft.
66989	Extracapsular cataract removal with insertion of intraocular lens prosthesis, complex, with insertion of intraocular anterior segment aqueous drainage device, without extraocular reservoir, internal approach, one or more.
66991	Extracapsular cataract removal with insertion of intraocular lens prosthesis, one-stage procedure, with insertion of intraocular anterior segment aqueous drainage device, without extraocular reservoir, internal approach, one or more.

HCPCS CodesHCPCS

C1783	Ocular implant, aqueous drainage assist device.
L8612	Aqueous shunt.

ICD10 CodesICD-10

E08.36	Diabetes mellitus due to underlying condition with diabetic cataract.
E09.36	Drug or chemical induced diabetes mellitus with diabetic cataract.
E10.36	Type 1 diabetes mellitus with diabetic cataract.
E11.36	Type 2 diabetes mellitus with diabetic cataract.
E13.36	Other specified diabetes mellitus with diabetic cataract.
H25.011-H25.9	Age-related cataract (code range).
H26.011-H26.069	Infantile and juvenile cataract (code range).
H26.101-H26.139	Traumatic cataract (code range).
H26.20	Unspecified complicated cataract.
H26.211-H26.219	Cataract with neovascularization (code range).

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ICD10 CodesICD-10

H40.001-H40.009	Preglaucoma, unspecified (code range).
H40.011-H40.029	Open angle with borderline findings (code range).
H40.031-H40.039	Anatomical narrow angle (code range).
H40.041-H40.049	Steroid responder (code range).
H40.051-H40.059	Ocular hypertension (code range).
H40.069
H40.10x4
H40.1111-H40.1134
H40.1210-H40.1294
H40.1310-H40.1394

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Provider and Billing Actions

Documentation Required

Verify Product Benefit Coverage

Verify that the member’s specific product covers the requested aqueous drainage device service before applying the policy’s investigational or coverage criteria. Services are contract dependent; if the product does not cover the service, medical policy criteria do not apply.

Documentation Required

Check Medicaid and eMedNY Guidance

For Medicaid products, check applicable New York State Medicaid guidance and eMedNY criteria before applying this policy. If no applicable eMedNY criteria exist, apply the medical policy criteria to the benefit.

Denial Risk

Suprachoroidal or Supraciliary Placement

Clinical Background

Glaucoma is a chronic disorder involving increased intraocular pressure (IOP), which can cause optic nerve damage and visual field loss. Topical or oral medication is generally the initial treatment. When target IOP cannot be reached or medications are not tolerated, aqueous shunts and other drainage devices may provide an alternate route for aqueous humor drainage. These devices, also called glaucoma drainage devices, setons, tube implants, or tube shunts, create an alternate pathway for fluid to drain from the eye. Micro-stents are minimally invasive glaucoma surgery devices commonly studied or used with cataract surgery in patients with mild-to-moderate open-angle glaucoma.

Definitions

Glaucoma

ConditionA chronic disorder involving increased pressure in the eye due to fluid build-up.

Untreated diseaseUntreated glaucoma may cause partial or complete visual impairment.

Clinical consequenceIncreased intraocular pressure can contribute to optic nerve damage and visual field loss.

Open-angle glaucoma (OAG)

PrevalenceOpen-angle glaucoma (OAG) is the most common form of glaucoma.

Pressure effectIncreased intraocular pressure associated with OAG can lead to optic neuropathy.

Potential damage

Policy Summary

PayerExcellus Health Plan Inc

PolicyAqueous Drainage Devices (Stents and Shunts) for Glaucoma

Policy CodePolicy 9.01.18

Change TypeAnnual reviewtitle revised

Effective DateJanuary 22, 2026

Next Review DateJanuary 1, 2027

Key ActionConfirm that the member’s specific product covers the requested service before applying the medical policy criteria.

SourceLink

On This Page

Treat insertion of an aqueous drainage device into the suprachoroidal or supraciliary space as investigational.

Suprachoroidal placement is investigational.
Supraciliary placement is investigational.

Denial Risk

Other Non-Qualifying Uses

Treat all other uses of aqueous drainage devices as investigational, including use in patients with glaucoma when intraocular pressure (IOP) is adequately controlled by medications.

Other non-qualifying uses are investigational.
Adequately medication-controlled IOP does not establish a qualifying use.

Billing Rule

Coverage Is Not Automatic

Do not assume that a listed code is covered. Codes may not be covered under all circumstances; confirm the member’s benefit and the circumstances of the service before billing.

Denial Risk

Experimental or Investigational Coding

Review coding designations and apply the policy’s investigational status when a procedure is identified as experimental or investigational. Such procedures may be subject to noncoverage.

0253T is identified as experimental/investigational for insertion into the suprachoroidal space.
0474T is identified as experimental/investigational for insertion into the supraciliary space.
Procedures marked E/I may be subject to noncoverage.

OAG may cause visual field loss and structural damage to the optic nerve fiber.

Aqueous drainage device

SynonymsAlso called an aqueous shunt, glaucoma drainage device, seton, tube implant, or tube shunt.

ImplantationThe device is implanted into the eye to create an alternate path for aqueous humor to drain from the anterior or posterior chamber to a space between the conjunctiva and sclera.

PurposeThe drained aqueous humor is absorbed into the blood, thereby lowering intraocular pressure.

Minimally invasive glaucoma surgery (MIGS)

DefinitionMIGS refers to a group of surgical procedures performed using an ab interno approach with minimal trauma to ocular tissues.

Treatment targetsAvailable MIGS procedures target the trabecular meshwork, Schlemm's canal, or the subconjunctival space.

Common combinationMIGS procedures are commonly combined with phacoemulsification; some are FDA-approved only when performed concurrently with phacoemulsification.

(E/I)

AbbreviationE/I.

MeaningExperimental/Investigational.

Policy coding useThe designation identifies a procedure or service as experimental or investigational in the policy's code listings.

(NMN)

AbbreviationNMN.

MeaningNot medically necessary/appropriate.

Policy coding useThe designation identifies a service as not medically necessary or appropriate in the policy's code listings.