Sierra Health and Life Glaucoma Coverage Update

Coverage Summary

This policy (Glaucoma Surgical Treatments, policy number 2026T0443LL) is effective January 1, 2026 and applies to UnitedHealthcare Commercial and Individual Exchange plans. The policy takes a mixed coverage stance: it lists specific glaucoma surgical and laser procedures that are considered proven and medically necessary and identifies other procedures (certain laser types) as unproven and not medically necessary.

Policy thresholds and quick facts

Policy number2026T0443LL

Effective dateJanuary 1, 2026

StatusCURRENT

Scope summaryMedical policy for UnitedHealthcare Commercial and Individual Exchange plans defining medically necessary glaucoma surgical treatments (pediatric and adult indications) and applicable codes; part 1 of 5 includes proven procedures, codes, service descriptions, and evidence summaries.

Pediatric age threshold≤ 18 years for goniotomy or trabeculotomy

Adult age threshold≥ 19 years for certain procedures when combined with cataract surgery

Proven / Medically Necessary and Not Medically Necessary Criteria

Proven and Medically Necessary Procedures (summary)

The following procedures are listed as proven and medically necessary:

Proven procedures

Pediatric goniotomy/trabeculotomy: Goniotomy or trabeculotomy for pediatric glaucoma (age 18 years or less)Age ≤ 18 years
Canaloplasty/combined with cataract (adults): Goniotomy, trabeculotomy, canaloplasty (ab interno), or combined canaloplasty (ab interno) and trabeculotomy (e.g., OMNI Surgical System, Streamline Surgical System) for adults (age 19 years or more) when used in combination with cataract surgery for treating mild to moderate open-angle glaucoma (OAG) and cataract in adults currently being treated with ocular hypotensive medicationAge ≥ 19 years; mild-to-moderate OAG; concurrent cataract surgery; on ocular hypotensive medication
Examples: OMNI, Streamline

Applicable CPT / HCPCS and Referenced Devices

Billing Rule

Evidence-based rationale for procedure selection: Document clinical findings, diagnostic testing (e.g., optic nerve imaging, reliable visual fields, IOP measurements), prior medical therapy and response, and rationale for selecting a specific surgical or laser approach versus alternatives. Use guideline and evidence context (AAO Preferred Practice Patterns, NICE) to support choice of MIGS, canaloplasty, trabeculectomy, trabeculotomy, goniotomy, or laser procedures based on glaucoma severity, angle anatomy, prior surgeries, and goals for IOP lowering. Postoperative follow-up and interventions: Document planned postoperative visits, IOP monitoring schedule, medication adjustments, interventions for complications (e.g., needling, wound revision, additional laser), and criteria for success or retreatment. Include documentation of patient counseling on expected outcomes and potential need for additional procedures. Use evidence and guideline context when considering MIGS or laser procedures: When considering minimally invasive glaucoma surgery (MIGS) or laser trabeculoplasty, reference current evidence and specialty guidelines regarding indications (e.g., mild–moderate OAG with cataract for some MIGS devices), comparative effectiveness, and limitations of evidence for standalone use where applicable. Off-label use warning (iStent standalone): Note that the iStent devices have demonstrated indications when used in combination with cataract surgery; standalone use may be off-label and requires clear documentation of rationale and supporting evidence if performed. Use of third-party tools: When using proprietary third-party systems (e.g., OMNI Surgical System, Streamline Surgical System, KDB, Trabectome, iStent, Hydrus, XEN, Ex-PRESS), document device model, FDA-clearance/approval status, procedural details, and any device-specific postoperative management. Ensure billing reflects the specific device and procedure codes used.

Provider Actions and Prior Authorization Notes

Prior Authorization

Prior authorization and plan applicability

When deciding coverage or preparing records, reference the member specific benefit plan document and check plan/federal/state mandates. UnitedHealthcare may apply this Medical Policy to Medicare Advantage plans where no NCD/LCD exists and may use third-party tools (e.g., InterQual) to assist in administering benefits. Document the clinical indication and prior treatments for refractory glaucoma when applicable, and include procedure-specific evidence or rationale and postoperative interventions as described in the policy. If performing or billing for procedures reflected in the updated code list, include updated codes (e.g., 1012T) on claims. For iStent standalone use, document that this is off-label if performed. Clinicians should document need for postoperative interventions (e.g., XEN needling) and rationale consistent with device labeling and guidelines.

Document indication and prior treatments for refractory glaucoma (evidence of failed or inappropriate prior medical/surgical therapy).
Document procedure-specific evidence and guideline rationale when selecting MIGS or laser procedures.
Document postoperative follow-up and interventions (e.g., needling for XEN) in the medical record.
Reference member-specific benefit plan and applicable mandates for coverage determinations.
Use updated applicable CPT codes on claims (including added code 1012T).
If iStent is used standalone, document off-label use.

Background and Evidence Summary

Glaucoma encompasses a group of eye diseases characterized by optic nerve damage and visual field loss related to elevated intraocular pressure (IOP); disease severity is categorized as mild, moderate, or severe based on structural and visual-field findings. Surgical and laser treatment options include traditional filtering/incisional surgeries (e.g., trabeculectomy, trabeculectomy with mitomycin C), aqueous shunts/glaucoma drainage devices (e.g., Ex-PRESS, Ahmed, Baerveldt, Molteno, XEN), cyclodestructive procedures (cyclophotocoagulation), laser angle procedures (laser trabeculoplasty including ALT and SLT), laser iridotomy/iridectomy, and laser iridoplasty.

Study/Source	Key finding/implication
Lee et al. 2023 (Systematic review - pediatric PCG)	Illuminated microcatheter-assisted circumferential trabeculotomy (IMCT) superior to conventional partial trabeculotomy (CPT) for IOP reduction and surgical success at 6 months; overall limited evidence; further long-term RCTs needed.
Samuelson et al. 2019a (iStent inject RCT)	iStent inject + cataract achieved greater unmedicated diurnal IOP reduction vs cataract alone at 24 months (75.8% vs 61.9% achieved ≥20% reduction); favorable safety profile.
Systematic reviews/meta-analyses of iStent (Popovic 2018; Kahale 2023; Healey 2021)	Meta-analyses show iStent/iStent inject combined with phaco reduces IOP and medication burden versus phaco alone with modest magnitude; evidence heterogeneous but generally favorable up to 3–5 years.
HORIZON trial / Ahmed et al. 2021, 2022, 5-year update	Hydrus microstent + cataract increased medication-free proportion and reduced need for additional glaucoma surgery vs cataract alone at 3 and 5 years; moderate-certainty evidence of sustained benefit.
Hydrus systematic reviews (Otarola 2020; Hu 2022; ECRI 2019/2024)	RCTs and reviews indicate Hydrus+phaco reduces IOP and medications versus phaco alone up to 5 years; may outperform iStent in some analyses; safety profile acceptable though data limited.
Sun et al. 2019 (EX-PRESS vs trabeculectomy meta-analysis)	EX-PRESS had better percent IOP reduction at 12 months and higher complete success at 1 year (OR=3.26), fewer increased IOP and hyphema events, and less postoperative intervention vs trabeculectomy.
Luo et al. 2023 (Tube shunts vs trabeculectomy meta-analysis)	Ahmed and EX-PRESS comparable to trabeculectomy for IOP outcomes; Baerveldt and XEN had worse IOP outcomes vs trabeculectomy; adverse event profiles vary by device.
ECRI / Hayes assessments of XEN (ECRI 2025; Hayes 2019/2023; Chen 2022)	Observational studies show XEN lowers IOP (≈25–56%) to mean ~15 mmHg; needling and postoperative interventions common; comparative effectiveness vs trabeculectomy mixed and evidence low quality.
LIGHT trial (Gazzard et al. 2022)	Selective laser trabeculoplasty (SLT) as initial therapy: ~69.8% of eyes at or below target IOP without medical/surgical intervention at 6 years and less progression vs drops; supports SLT effectiveness as primary therapy.
Baskaran et al. 2022 (LPI RCT)	Prophylactic laser peripheral iridotomy reduced incidence of PAC/PACG endpoints over 5 years; NNT=22 to prevent an endpoint.
Cochrane review on cyclodestructive procedures (Chen 2019)	Evidence inconclusive versus other procedures; adverse events include hypotony and phthisis; trials small and heterogeneous; safety concerns noted.
Goldberg et al. 2024 / VENICE interim RCT and Streamline vs iStent W (interim)	Interim 6-month RCT data (Streamline canaloplasty vs iStent W) show similar mean IOP and medication reductions at 6 months; trial ongoing with short follow-up and potential sponsor bias.
Hayes HTA Canaloplasty (2020, updated 2023)	Concluded insufficient evidence to assess effectiveness and safety of ab-interno canaloplasty (evidence gap for canaloplasty procedures).
VISCO360 / ABiC / OMNI case series (Ondrejka & Korber 2019/2022; Gallardo 2018; ECRI OMNI 2021/2023)	Case series report reduced mean IOP and medication use at 12 months with ABiC/OMNI/VISCO360; OMNI evidence very-low to low quality suggesting IOP and medication reduction up to 24 months; comparative effectiveness not established.
GEMINI / OMNI (Gallardo/Pyfer) case series and GEMINI interim results	High proportion medication-free at 6–12 months after combined canaloplasty and trabeculotomy with phaco (e.g., GEMINI: substantial IOP and medication reductions), but studies lack randomized controls and have short follow-up.
GATT and Trabectome evidence (Grover 2018; Hu 2021; systematic reviews)	GATT case series show meaningful IOP and medication reductions through 24 months; overall evidence low quality with few RCTs for ab interno trabeculotomy and Trabectome.
KDB vs iStent and comparative studies (Falkenberry 2020; ElMallah 2019; Dorairaj 2018; systematic reviews)	Mixed findings: some RCTs/observational studies show phaco-KDB may have higher early surgical success and greater proportion achieving ≥20% IOP reduction at 6–12 months vs phaco-iStent, but by 12–24 months IOP reductions often comparable; heterogeneity and bias present.
FLIGHT femtosecond trabeculotomy (Nagy et al. 2023)	Single-arm 24-month study (small) reported mean IOP reduction 34.6% and 82.3% achieving ≥20% IOP reduction at 24 months; promising safety but limited by single-arm design and small sample.
ECRI assessments (KDB, OMNI, Streamline) and AAO guidance (AAO PPP 2020; Ophthalmic Technology Assessments)	ECRI and AAO note MIGS generally less effective than trabeculectomy/aquous shunts but favorable safety; many MIGS devices have limited long-term RCT data and are often approved only with cataract surgery.
EX-PRESS long-term RCT extension (de Jong 2011) and meta-analyses	Five-year RCT extension showed EX-PRESS provided better early IOP control and higher complete success rates than trabeculectomy with fewer interventions through year 3; supports EX-PRESS efficacy.
OMNI/Streamline case series and small RCTs (Lazcano-Gomez 2022; Toneatto 2022; Gallardo 2021/2022)	Combined ab interno canaloplasty and trabeculotomy with phaco (OMNI/Streamline) shows substantial IOP and medication reductions and high medication-free rates at 6–12 months, but evidence largely nonrandomized and short-term.
Falkenberry et al. 2020 (KDB vs iStent RCT)	Randomized trial comparing excisional goniotomy (KDB) vs iStent (first gen) with phaco: composite outcome favored KDB at 12 months (post-hoc); mean IOP and medication reductions similar; results subject to post-hoc analysis concerns and study limitations.
ElMallah et al. 2019; Dorairaj et al. 2018 (retrospective comparative studies)	Retrospective comparisons report higher proportions achieving ≥20% IOP reduction with phaco-KDB versus phaco-iStent at 6–12 months; baseline differences and nonrandomized design limit conclusions.
Multiple device/technology assessments and RCTs cited across policy (references summary)	Overall evidence base comprises RCTs (Hydrus HORIZON, iStent pivotal trials, LIGHT), systematic reviews, meta-analyses, and many observational series — findings support some MIGS and laser procedures in specific settings but highlight heterogeneity, limited long-term RCT data for many devices, and variable safety/need for postoperative interventions.

Definitions (compact)

MIGSMicroinvasive/minimally invasive glaucoma surgery — newer, typically ab interno procedures often combined with phacoemulsification; lower procedural risk but often less IOP reduction than filtering surgery

OAGOpen-angle glaucoma

PCGPrimary congenital glaucoma

ABiCAb-interno canaloplasty — microcatheter viscodilation of Schlemm's canal (standalone or with cataract extraction)

Policy Thresholds and Age Criteria

Thresholds mapped to criteria

Age for pediatric indication≤ 18 years (goniotomy or trabeculotomy)

Adult indication age≥ 19 years (procedures such as goniotomy, trabeculotomy, ab-interno canaloplasty, OMNI/Streamline when combined with cataract surgery)

Where thresholds applySee proven/medically necessary criteria group for pediatric vs adult procedural indications (goniotomy/trabeculotomy pediatric; adult canal-based procedures when combined with cataract surgery)

Revision History

01/01/2026policy_effectiveLatest

Template Update: Created shared policy version to support application to Oxford plan membership; updated applicable CPT codes to reflect annual edits and added code 1012T; archived previous policy version 2025T0443KK.