Glaucoma Surgical Treatments (for Nebraska Only)

Coverage Summary

This UnitedHealthcare medical policy (Policy Number CS050NE.X) applies only to the State of Nebraska and defines coverage for glaucoma surgical treatments. The policy identifies specific procedures as proven and medically necessary and others as unproven or not medically necessary, and it provides associated procedure and HCPCS/CPT codes for reference. The policy is effective March 1, 2026.

Key thresholds and scope

Age for pediatric indication≤ 18 years

Age for adult indication≥ 19 years

MIGS expected benefitAt least 20% IOP reduction or reduction of at least one glaucoma medication

Policy applies to StateNebraska

Medical-Necessity Criteria

Proven and Medically Necessary Procedures

The following are proven and medically necessary:

Goniotomy or trabeculotomy (pediatric): Goniotomy or trabeculotomy for pediatric glaucoma (age 18 years or less)
Age ≤ 18 years
Canaloplasty / trabeculotomy combined with cataract (adult): 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 medication
Age ≥ 19 years; must be combined with cataract surgery; indication: mild to moderate OAG with cataract and currently on ocular hypotensive medication
iStent / iStent inject / Hydrus with cataract (adult): iStent, iStent inject, or Hydrus Microstent 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 medication

Not Medically Necessary / Unproven

All other FDA approved types of laser procedures are unproven and not medically necessary for treating any type of glaucoma due to insufficient evidence of efficacy and/or safety.

Unproven/Not Medically Necessary Laser Procedures: Any FDA-approved laser procedure for glaucoma not explicitly listed as proven above

Examples include excimer laser trabeculostomy/trabeculotomy (ELT), femtosecond laser trabeculotomy (FLT), OCT-guided laser trabeculotomy and other laser treatments not listed as proven; insufficient quality evidence of safety and efficacy

Coding

Referenced CPT / HCPCS codes (for procedures described)mixed

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.
0474T	Insertion of anterior segment aqueous drainage device, with creation of intraocular reservoir, internal approach, into the supraciliary space.
0621T	Trabeculostomy ab interno by laser.
0622T	Trabeculostomy ab interno by laser; with use of ophthalmic endoscope.
0671T	Insertion of anterior segment aqueous drainage device into the trabecular meshwork, without external reservoir, and without concomitant cataract removal, one or more.
0730T	Trabeculotomy by laser, including OCT guidance.
1012T	Motorized ab interno trephination of sclera (sclerostomy), or trabecular meshwork (trabeculostomy), 1 or more, including injection of antifibrotic agents, when performed.
65820	Goniotomy.

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FDA-approved devices and predicates mentioned (informational)mixed

K062259	Canaloplasty Ophthalmic Microcannula (iTRACK) - FDA PMN
K211680	Streamline Surgical System (Streamline Viscoelastic Injector) - FDA K
K030350	EX-PRESS Mini Glaucoma Shunt - FDA 501(k)
K890598	Molteno Implant (predicate)
K902489	Molteno Implant (predicate)
K905129	Baerveldt Glaucoma Implant (predicate)
K955455	Baerveldt Glaucoma Implant (predicate)
K885125	Krupin Eye Valve (predicate)
K905703	Krupin Eye Valve (predicate)
K925636	Ahmed Glaucoma Valve Implant (predicate)

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Updated Applicable CPT CodesCPT

1012T

Added to list of applicable CPT codes (effective 03/01/2026)

Provider Actions

Documentation Required

Indication documentation for combined procedures

Document diagnosis of mild to moderate open-angle glaucoma, presence of visually significant cataract, and that the patient is currently using ocular hypotensive medication when performing procedures combined with cataract surgery (examples: canaloplasty ab interno, trabeculotomy, iStent, Hydrus).

Diagnosis: mild to moderate OAG
Presence of cataract
Current use of ocular hypotensive medication

Documentation Required

Pediatric goniotomy/trabeculotomy documentation

Document patient age (≤18 years) and the diagnosis of pediatric glaucoma when performing goniotomy or trabeculotomy in pediatric patients.

Background & Evidence Summary

Glaucoma is a chronic, progressive optic neuropathy characterized by optic nerve and retinal nerve fiber layer abnormalities and visual field loss; severity is categorized as mild, moderate, severe, or indeterminate based on optic nerve/RNFL findings and standard automated perimetry (SAP).

Surgical options described include ab externo and ab interno canaloplasty (viscodilation of Schlemm’s canal), goniotomy, trabeculotomy (including circumferential/GATT), trabeculectomy, glaucoma drainage devices/shunts (e.g., EX-PRESS, Molteno, Baerveldt, Ahmed, Krupin, XEN), various MIGS approaches (trabecular bypass stents such as iStent/iStent inject, Hydrus; excisional goniotomy such as KDB; trabeculotomy/viscodilation devices such as OMNI, Streamline; ab interno canaloplasty/ABiC; suprachoroidal and subconjunctival shunts), and cyclophotocoagulation/ciliary body destruction. Laser procedures described include trabeculoplasty (ALT, SLT), iridotomy, and iridoplasty.

Microinvasive glaucoma surgery (MIGS) is defined as typically ab interno procedures usually combined with phacoemulsification, with a more favorable short-term safety profile but generally less IOP lowering than traditional filtering surgery. MIGS candidates are generally those with mild to moderate glaucoma and the procedures are expected to provide at least a 20% IOP reduction or a reduction of at least one glaucoma medication; many MIGS devices are indicated only when combined with cataract surgery.

Evidence topic	Summary
Pediatric surgical evidence	Multiple systematic reviews and RCTs support goniotomy/trabeculotomy for pediatric glaucoma; microcatheter-assisted circumferential trabeculotomy (IMCT) may be superior to conventional partial trabeculotomy but further long-term RCTs are needed
iStent combined with phaco evidence	Systematic reviews and RCTs show combined iStent (including iStent inject) plus cataract surgery reduces IOP and medication burden versus cataract alone with durable reductions up to 3–5 years in some studies
Hydrus evidence	RCTs (HORIZON) and systematic reviews indicate Hydrus plus cataract surgery increases medication-free rates and reduces need for additional glaucoma surgery versus cataract alone through 3–5 years; may be more effective than iStent short-term
Laser trabeculoplasty (LIGHT trial)	LIGHT trial: SLT provided better long-term disease control than drops; at 6 years ~69.8% in SLT arm remained at or below target IOP without medical/surgical intervention
Cyclodestructive procedures	Cochrane review: evidence inconclusive vs other glaucoma treatments; adverse events include hypotony and phthisis bulbi; larger RCTs needed
Canaloplasty (VENICE interim)	VENICE interim 6‑month RCT (Streamline vs iStent W, n=72): similar mean IOP reductions at 6 months; medication-free rates slightly higher for Streamline; study ongoing
OMNI	Case series and GEMINI/Gallardo studies: OMNI with phaco reduced mean diurnal IOP and medication use with ~78–80% medication-free at 6–12 months; evidence low quality, lacks randomized comparisons
KDB vs iStent	Systematic reviews, RCTs and comparative cohorts show phaco-KDB may have greater early surgical success versus phaco-iStent; by 12–24 months IOP reductions often become comparable; heterogeneity and bias limit conclusions
XEN Gel Stent evidence	Systematic reviews and observational studies indicate XEN lowers IOP (~25–44%) and medications with frequent needling and postoperative interventions; comparative studies suggest trabeculectomy may be somewhat more effective; evidence largely nonrandomized

Definitions

MIGS

Revision History

2026-03-01material_changeLatest

Added CPT code 1012T to the list of applicable CPT codes.

2026-03-01archival_note

Archived previous policy version CS050NE.W.