Glaucoma Surgical Treatments La Cs

Coverage Summary

This UnitedHealthcare Louisiana medical policy (CS050LA.U) for Glaucoma Surgical Treatments is marked RETIRED with a retirement effective date of 2026-04-01. The policy's stated effective window was February 1, 2026 – March 31, 2026 and applies only to the State of Louisiana.

The policy defines covered procedure categories at a high level: pediatric goniotomy/trabeculotomy for patients aged ≤18 years; selected adult procedures when performed in combination with cataract surgery (including ab interno canaloplasty, trabeculotomy, and trabecular microstents such as iStent, iStent inject, and Hydrus for mild-to-moderate open-angle glaucoma); glaucoma drainage devices (e.g., XEN, EX-PRESS, Molteno, Baerveldt, Ahmed, Krupin-Denver) for refractory glaucoma after failed or inappropriate prior medical/surgical therapy; and proven laser procedures (laser trabeculoplasty, laser iridotomy/iridectomy, laser iridoplasty, and laser ciliary body destruction).

Key facts

Effective DateFebruary 1, 2026 - March 31, 2026

Policy StatusRETIRED (retired April 1, 2026)

Geographic scopeApplies to Louisiana only

Retirement event datePolicy retired; Louisiana membership disenrolled April 1, 2026

Policy numberCS050LA.U

MIGS efficacy expectationProcedures should offer at least 20% IOP reduction or reduce at least one medication

Medical-Necessity Criteria

Proven and Medically Necessary Procedures

The following procedures are considered proven and medically necessary under this policy for the stated populations:

ALL of the following

Pediatric (age 18 years or less)
- Goniotomy or trabeculotomy for pediatric glaucoma (age 18 years or less)
Adults (age 19 years or more) when combined with cataract surgery for mild to moderate OAG in adults currently being treated with ocular hypotensive medication
- Goniotomy, trabeculotomy, canaloplasty (ab interno), or combined canaloplasty (ab interno) and trabeculotomy (e.g., OMNI Surgical System, Streamline Surgical System) 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

Applicable Procedure and Device Codes

Applicable CPT / HCPCS / Other procedure codes (reference list)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 optical coherence tomography (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.

1–10 of 23

1/3

Codes not on Louisiana Medicaid Fee Schedule (asterisked)mixed

0253T	Not on State of Louisiana Medicaid Fee Schedule.
0449T	Not on State of Louisiana Medicaid Fee Schedule.
0450T	Not on State of Louisiana Medicaid Fee Schedule.
0474T	Not on State of Louisiana Medicaid Fee Schedule.
0621T	Not on State of Louisiana Medicaid Fee Schedule.
0622T	Not on State of Louisiana Medicaid Fee Schedule.
0671T	Not on State of Louisiana Medicaid Fee Schedule.
0730T	Not on State of Louisiana Medicaid Fee Schedule.

FDA-cleared/approved devices mentionedmixed

K062259	Canaloplasty Ophthalmic Microcannula (iTRACK) - FDA PMN (approved August 2006).
K211680	Streamline Surgical System / Streamline Viscoelastic Injector - FDA K211680.
K030350	ExPRESS Mini Glaucoma Shunt - FDA K030350 (approved March 26, 2002).
K170043	PMA P170043 referenced for iStent inject PMA (iStent inject PMA approved June 21, 2018).
GTS100R/L	iStent Trabecular Micro-Bypass Stent System Model GTS100R/L (FDA approved June 25, 2012).
P170034	Hydrus Microstent (P170034) - FDA PMA approved August 10, 2018.
K161457	XEN Glaucoma Treatment System - K161457 (approved November 21, 2016).
K230722	Eagle selective laser trabeculoplasty device - K230722 (approved December 12, 2023).
K140336	OPTIMIS FUSION Ophthalmic Laser Systems family - K140336 (approved June 25, 2014).

Applicable CPT codes (updated)CPT

1012T

Added to list of applicable CPT codes (policy history note).

Codes not on Louisiana Medicaid Fee Schedule (asterisked)mixed

0253T	Not on State of Louisiana Medicaid Fee Schedule.
0449T	Not on State of Louisiana Medicaid Fee Schedule.
0450T	Not on State of Louisiana Medicaid Fee Schedule.
0474T	Not on State of Louisiana Medicaid Fee Schedule.
0621T	Not on State of Louisiana Medicaid Fee Schedule.
0622T	Not on State of Louisiana Medicaid Fee Schedule.
0671T	Not on State of Louisiana Medicaid Fee Schedule.
0730T	Not on State of Louisiana Medicaid Fee Schedule.

FDA-cleared/approved devices mentionedmixed

K062259	Canaloplasty Ophthalmic Microcannula (iTRACK) - flexible microcannula (FDA PMN K062259, approved August 2006).
K211680	Streamline Surgical System / Streamline Viscoelastic Injector (FDA K211680).
K030350	ExPRESS Mini Glaucoma Shunt (FDA K030350, 501(k) approval March 26, 2002).
P170034	Hydrus Microstent (PMA P170034) - FDA PMA approved August 10, 2018.
GTS100R/L	iStent Trabecular Micro-Bypass Stent System Model GTS100R/L (FDA approved June 25, 2012).
K170043	iStent inject PMA (P170043) - FDA PMA approved June 21, 2018.
K161457	XEN Glaucoma Treatment System (K161457) - FDA approval November 21, 2016.
K230722	Eagle device for SLT (K230722) - FDA approved December 12, 2023.
K140336	OPTIMIS FUSION Ophthalmic Laser Systems family (K140336) - FDA approved June 25, 2014.

Applicable CPT codes (updated)CPT

1012T

Added to list of applicable CPT codes (policy history note).

Provider Actions & Billing Guidance

Billing Rule

Reference codes for billing

Use the CPT/HCPCS codes listed below for claim submission when reporting glaucoma surgical procedures. Inclusion of a code in this list is for reference and does not guarantee coverage. Codes marked with an asterisk (*) may not be covered by the State of Louisiana Medicaid Fee Schedule; check member benefits and contractual terms prior to billing.

*0253T
*0449T
*0450T
*0474T
*0621T
*0622T
*0671T
*0730T
1012T
65820
65855
66174
66175
66179
66180

Background and Definitions

The policy summarizes glaucoma as a group of diseases characterized by elevated intraocular pressure (IOP) leading to optic nerve damage and visual field loss, and it defines severity categories as Mild, Moderate, Severe, and Indeterminate based on optic nerve/RNFL findings and standard automated perimetry (SAP).

Procedural descriptions in the policy include: canaloplasty (historically ab externo and more recently ab interno approaches) that viscodilates Schlemm's canal; cyclophotocoagulation (CPC) for ciliary body destruction to reduce aqueous production; laser iridoplasty to contract peripheral iris and open the angle; laser peripheral iridotomy (LPI) to relieve pupillary block; laser trabeculoplasty (ALT and SLT) to increase trabecular outflow; trabeculectomy to create a subconjunctival filtering bleb; goniotomy and ab interno trabeculotomy (including KDB, Trabectome) to incise/excise trabecular meshwork; gonioscopy-assisted transluminal trabeculotomy (GATT) for circumferential trabeculotomy; MIGS approaches (trabecular bypass stents, tissue-excising goniotomy, Schlemm's canal viscodilation/ab interno canaloplasty, suprachoroidal approaches, subconjunctival shunts, and ciliary body ablation); and glaucoma drainage devices (ExPRESS, Molteno, Baerveldt, Ahmed, Krupin-Denver, XEN) with device-specific descriptions.

The policy positions MIGS as generally intended for mild-to-moderate glaucoma, typically performed via an ab interno approach and often combined with phacoemulsification. MIGS procedures are expected to provide at least a 20% IOP reduction or an alternative benefit of reducing IOP-lowering medication by at least one medication, and they are noted to deliver modest IOP lowering with more favorable short-term safety compared with traditional filtering surgery.

Term	Definition
MIGS
Microinvasive or minimally invasive glaucoma surgery; typically ab interno, often combined with phacoemulsification, intended for mild to moderate glaucoma; procedures should offer at least 20% IOP reduction or alternatively, an IOP reduction of at least one medication.
OAG/POAG
Open-angle glaucoma / Primary open-angle glaucoma (POAG): chronic, progressive optic neuropathy with optic nerve/RNFL structural abnormalities and reproducible visual field defects; adult onset with open anterior chamber angles.
CPC
Cyclophotocoagulation (CPC): laser ciliary body destruction to damage ciliary epithelium and reduce aqueous humor production, lowering IOP.
GATT
Gonioscopy-assisted transluminal trabeculotomy (GATT): an ab interno circumferential trabeculotomy performed by microcatheter or suture guided circumferentially through Schlemm's canal to create a 360-degree trabeculotomy.
ELT
Excimer laser trabeculotomy/trabeculostomy (ELT): a laser trabecular meshwork procedure; evidence limited and not FDA approved for glaucoma in the US.
FLIGHT
Femtosecond laser, image-guided, high-precision trabeculotomy (FLIGHT): a noninvasive laser trabeculotomy approach with early single‑arm data showing IOP reductions and ~82% achieving ≥20% IOP reduction at 24 months; further study needed.

Evidence Summary

The policy's evidence summary cites randomized controlled trials, systematic reviews, and meta-analyses with variable quality across interventions. Key RCTs and systematic reviews highlighted include the iStent inject pivotal RCT (Samuelson et al. 2019) showing greater proportions achieving ≥20% unmedicated diurnal IOP reduction at 24 months with iStent inject plus cataract versus cataract alone, and Hydrus HORIZON trial reports (Ahmed et al.) demonstrating increased medication-free eyes and reduced need for additional surgery sustained to 3–5 years.

Comparative evidence notes moderate-certainty findings that Hydrus may be more effective than iStent for short-term IOP lowering, and meta-analyses/RTC evidence support EX-PRESS showing favorable IOP control versus trabeculectomy in early years. The LIGHT trial (Gazzard et al.) demonstrated durable benefit of SLT as initial therapy over drops at six years, while LPI RCTs (Baskaran et al.) support prophylactic LPI reducing progression in PACS. Systematic reviews (Cochrane) find cyclodestructive procedures evidence inconclusive and highlight common adverse events.

For newer devices and procedures the evidence is more limited or low quality: XEN has multiple observational studies and systematic reviews but few large RCTs and mixed/low-quality evidence with frequent needling and postoperative interventions; canaloplasty (ab interno) has insufficient evidence per Hayes and interim VENICE RCT results (Goldberg 2024) and other case series showing short-term reductions but lacking long-term RCT data; combined canaloplasty + trabeculotomy (OMNI/Streamline) and other canal-based MIGS have low-to-very-low quality evidence from case series and small comparative studies suggesting IOP and medication reductions up to 12–24 months but lacking definitive randomized comparisons. Overall, evidence strength is variable and often low for many devices, as reflected throughout the brief.

Quantitative evidence highlights

Revision History

2026-02-01policy_revision

Updated list of applicable CPT codes to reflect annual edits; added 1012T.

2026-02-01archived_note

Supporting information: archived previous policy version CS050LA.T (archived previous policy version noted).

2026-02-01 to 2026-03-31policy_effective_period

Document header indicates retirement effective 2026-04-01 and a short effective period covering Feb–Mar 2026 (Effective Date: February 1, 2026 - March 31, 2026).