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CurrentUnitedHealthcarePolicy CSNCT0443.05

Glaucoma Surgical Treatments (for North Carolina Only)

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Coverage of glaucoma surgical and laser procedures for UnitedHealthcare Community Plan members in North Carolina, including adult, pediatric, refractory glaucoma, and cataract-associated procedures.

Policy Summary

PayerUnitedHealthcare

PolicyGlaucoma Surgical Treatments (for North Carolina Only)

Policy CodePolicy CSNCT0443.05

Change TypeNo material clinical or coverage change

Effective DateOctober 1, 2026

Next Review DateNot specified

Key ActionDocument the glaucoma diagnosis and severity, baseline and follow-up IOP, medication use, cataract surgery status, treatment response, and clinical rationale when requesting review for newer laser or MIGS procedures.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

NCApplicable state

19+ yearsAdult threshold for specified combined procedures

≤18 yearsPediatric threshold for goniotomy or trabeculotomy

Mild–moderateCovered adult glaucoma severity

Not medically necessaryOther FDA-approved laser procedures

Covered and Noncovered Glaucoma Procedures

Adult glaucoma procedures with cataract surgery

The following are proven and medically necessary:

Covered adult procedures combined with cataract surgery

Adult goniotomy, trabeculotomy, or canaloplasty pathway: Goniotomy, trabeculotomy, ab interno canaloplasty, or combined ab interno canaloplasty and trabeculotomy is performed in combination with cataract surgery for an adult age 19 years or more with mild to moderate open-angle glaucoma and cataract who is currently being treated with ocular hypotensive medication.Age 19 years or more; mild to moderate open-angle glaucoma; current ocular hypotensive medication
Examples include the OMNI Surgical System and Streamline Surgical System.
Trabecular microstent pathway: An iStent, iStent inject, or Hydrus Microstent is used in combination with cataract surgery for an adult with mild to moderate open-angle glaucoma and cataract who is currently being treated with ocular hypotensive medication.Mild to moderate open-angle glaucoma; current ocular hypotensive medication

Policy Summary

PayerUnitedHealthcare

PolicyGlaucoma Surgical Treatments (for North Carolina Only)

Policy CodePolicy CSNCT0443.05

Change TypeNo material clinical or coverage change

Effective DateOctober 1, 2026

Next Review DateNot specified

SourceLink

On This Page

Other laser procedures: insufficient or unclear evidence

Other laser procedures for glaucoma have limited, insufficient, or unclear evidence in this policy.

Other laser procedures for glaucoma, including excimer laser trabeculostomy or trabeculotomy (ELT), femtosecond laser trabeculotomy, and OCT-guided laser trabeculotomy, are not supported by sufficient high-quality clinical evidence.

Certain procedures are not currently U.S. FDA approved for glaucoma treatment; support for OCT-guided laser trabeculotomy is unclear. Evidence for ELT and femtosecond laser trabeculotomy is limited by study-design and follow-up limitations.

Related Codes, Devices, and Clinical Identifiers

Related CPT and HCPCS codesmixed

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
0621T	Trabeculostomy ab interno by laser
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
66174	Transluminal dilation of aqueous outflow canal (e.g., canaloplasty); without retention of device or stent
66179	Transluminal dilation of aqueous outflow canal (e.g., canaloplasty); with retention of device or stent
66180	Aqueous shunt to extraocular equatorial plate reservoir, external approach; without graft

1–10 of 17

1/2

FDA device and product identifiers for canaloplasty and related ophthalmic systemsmixed

HMX	Cannula, ophthalmic
MPA	Endoilluminator
MRH	Pump, infusion, ophthalmic
K062259	Canaloplasty Ophthalmic Microcannula or iTRACK
HMZ	Trabeculotomy
K211680	Streamline Surgical System, also known as the Streamline Viscoelastic Injector

FDA-approved glaucoma drainage devices and trabecular microbypass systemsmixed

K030350	EX-PRESS mini glaucoma shunt
K890598	Molteno implant
K902489	Molteno implant
K905129	Baerveldt glaucoma implant
K955455	Baerveldt glaucoma implant
K885125	Krupin Eye Valve
K905703	Krupin Eye Valve
K925636	Ahmed Glaucoma Valve implant
KYF	Implant, eye valve
GTS100R/L	iStent trabecular microbypass stent system

1–10 of 12

1/2

FDA-approved glaucoma drainage and laser treatment devicesmixed

P170034	Hydrus Microstent
K161457	XEN Glaucoma Treatment System
K230722	Eagle device

FDA-approved Nd:YAG and SLT laser systemmixed

K140336

OPTIMIS FUSION ophthalmic laser systems, delivery device, and accessories

Clinical trial identifiermixed

NCT06246136

Prospective multicenter randomized clinical trial comparing ELIOS or a competitor device in participants with open-angle glaucoma undergoing cataract surgery

Medication reduction after combined phaco-ELIOS

Baseline medications1.8 ± 0.8 medications

12-month medications0.4 ± 0.7 medications

Reduction1.5 ± 1.0 medications

FLIGHT IOP reduction

Follow-up24 months

Mean IOP reduction34.6%

Eyes achieving at least 20% IOP reduction14 of 17 eyes (82.3%)

ELT failure criteria

Additional procedureNeed for another surgical glaucoma procedure

IOP criterionIOP greater than 21 mm Hg

Reduction criterionFailure to achieve a 20% reduction from baseline

Documentation and Review Considerations

Documentation Required

Clinical Evidence and Treatment History

For review of newer laser or MIGS procedures, submit the patient’s diagnosis and severity, treatment history, current ocular hypotensive medication use, prior medical or surgical response, and the proposed procedure. Include relevant clinical evidence and explain whether the procedure will be performed with cataract surgery or as a standalone treatment.

Document the glaucoma type and severity, cataract status, current medications, prior treatments, treatment failures or contraindications, and the clinical rationale for the requested procedure.
For procedures such as ELT, ELIOS, or FLIGHT, include the available supporting evidence and acknowledge that evidence may be limited by small samples, nonrandomized designs, lack of controls, short follow-up, or incomplete safety data.

Documentation Required

Identify the Device and Intended Use

Identify the exact device and intended use in the request, and document whether it is FDA-approved for the proposed glaucoma indication. For iStent, iStent inject, and Hydrus, document that the device is being used in conjunction with cataract surgery and that the patient meets the applicable adult mild-to-moderate open-angle glaucoma criteria.

Name the device, model when available, FDA approval or clearance information, intended use, and proposed procedure.
Document the planned combination with cataract surgery when required; standalone use of iStent inject is off label.

Denial Risk

Unlisted FDA-Approved Laser Procedure

All other FDA-approved types of laser procedures that are not specifically identified as proven are considered unproven and not medically necessary for treating any type of glaucoma. Verify that the requested laser procedure is one of the covered procedures before submitting for review.

Covered laser procedures identified in the policy include laser trabeculoplasty, laser iridotomy or iridectomy, laser ciliary body destruction, and laser iridoplasty.
An FDA approval alone does not establish coverage when the laser procedure is not specifically identified as proven in the policy.

Denial Risk

Adult Combined-Procedure Criteria Not Met

For adult combined goniotomy, trabeculotomy, canaloplasty, combined canaloplasty and trabeculotomy, or covered trabecular microstent procedures, coverage requires that the procedure be performed with cataract surgery for mild to moderate open-angle glaucoma and cataract in an adult age 19 or older who is currently receiving ocular hypotensive medication.

If any specified criterion is not met, document the reason and do not represent the procedure as meeting the policy’s proven and medically necessary criteria.
Include patient age, glaucoma severity and type, cataract diagnosis, current ocular hypotensive therapy, and the planned cataract-surgery combination.

Denial Risk

Refractory Glaucoma Requirement Not Met

Glaucoma drainage devices are covered for refractory glaucoma only when medical or surgical treatments have failed or are inappropriate. If refractoriness is not established, document the clinical rationale for the requested device or expect review concerns.

Describe the medical and surgical treatments tried, the response or failure of each treatment, and the dates or duration when available.
If treatment is inappropriate, explain the patient-specific contraindication or clinical reason it cannot be used.

Denial Risk

Insufficient Evidence or Lack of U.S. FDA Approval

Other laser procedures for glaucoma may be denied when published evidence is insufficient to establish safety and efficacy or when the procedure is not FDA approved for glaucoma treatment in the United States. This includes procedures such as ELT, femtosecond laser trabeculotomy, and OCT-guided laser trabeculotomy.

The policy notes insufficient quality evidence for other laser procedures, including limited or unclear support for OCT-guided laser trabeculotomy.
Approval for refractive or other surgical uses does not establish FDA approval for glaucoma treatment in the United States.

Note

Limited Evidence Base

The evidence base for ELT, ELIOS, and FLIGHT remains limited and may not establish durable comparative safety or efficacy. Requests should address these limitations and provide patient-specific justification and supporting clinical documentation.

ELIOS evidence is based on a combined phaco-ELIOS series without a control group, with no reported safety data and only 1-year follow-up; the individual effects of phacoemulsification and ELIOS could not be separated.
FLIGHT evidence comes from a small, single-arm, nonrandomized study with 18 eyes initially and risk of bias; larger multicenter randomized studies are needed.
ELT evidence includes small or nonrandomized studies, limited reporting of complications, variable loss to follow-up, lack of controls, and failure to demonstrate a long-lasting response; the policy also notes pending U.S. clinical studies.

Denial Risk

Device Indication or Off-Label Use

Confirm that the device’s FDA-labeled indication matches the proposed use. iStent, iStent inject, and Hydrus are approved in conjunction with cataract surgery for specified adult glaucoma populations, while standalone iStent inject use is off label and may not meet policy requirements.

iStent is indicated with cataract surgery for adults with mild to moderate open-angle glaucoma and cataract who are currently treated with IOP-lowering medication.
iStent inject is approved only with cataract surgery; standalone use is off label.
Hydrus is indicated with cataract surgery for adults with mild to moderate primary open-angle glaucoma.
The Eagle device is intended for selective laser trabeculoplasty, and OPTIMIS FUSION systems have specified uses including iridotomy and SLT; do not infer coverage for other laser applications.

Clinical Terms and Procedure Definitions

Mild glaucoma

Structural findingDefinite optic disc, retinal nerve fiber layer, or macular imaging abnormalities consistent with glaucoma

Visual fieldNormal visual field

Testing methodStandard automated perimetry

Moderate glaucoma

Structural findingDefinite optic disc, retinal nerve fiber layer, or macular imaging abnormalities consistent with glaucoma

Visual fieldAbnormalities in one hemifield, not within 5° of fixation

Testing methodStandard automated perimetry

Severe glaucoma

Structural findingDefinite optic disc, retinal nerve fiber layer, or macular imaging abnormalities consistent with glaucoma

Visual fieldAbnormalities in both hemifields and/or loss within 5° of fixation in at least one hemifield

Testing methodStandard automated perimetry

Indeterminate glaucoma

Structural findingDefinite optic disc, retinal nerve fiber layer, or macular imaging abnormalities consistent with glaucoma

Visual field testingUnable to perform, unreliable, or uninterpretable

Testing statusVisual field testing has not yet been performed

Microinvasive or minimally invasive glaucoma surgery (MIGS)

ApproachTypically performed through an ab interno approach

Common settingUsually combined with phacoemulsification surgery

Expected effectShould offer at least a 20% IOP reduction or a reduction of at least one medication

Laser peripheral iridotomy

ProcedureLaser creates a hole in the iris

Fluid pathwayAllows aqueous humor to move directly from the posterior to the anterior chamber

PurposeRelieves pupillary block

Laser iridoplasty

LaserLow-energy argon laser photocoagulation

Tissue effectContracts peripheral iris tissue away from the trabecular meshwork

PurposeOpens the anterior chamber angle and lowers IOP

PCG

AbbreviationPCG

MeaningPrimary congenital glaucoma

Clinical contextA pediatric glaucoma condition discussed in relation to angle surgery

GATT

AbbreviationGATT

ExpansionCircumferential gonioscopy-assisted transluminal trabeculotomy

Pediatric context360° or 180° angle surgery described in children with primary congenital glaucoma

JOAG

AbbreviationJOAG

MeaningJuvenile open-angle glaucoma

Patient contextOpen-angle glaucoma occurring in juvenile patients

OAG

AbbreviationOAG

MeaningOpen-angle glaucoma

Angle statusThe anterior chamber angle remains open

Primary angle closure

ConditionDevelopment of peripheral anterior synechiae and/or IOP greater than 21 mm Hg

Peripheral anterior synechiaeMay be present

IOP thresholdGreater than 21 mm Hg

Primary angle-closure suspect (PACS)

IOPNormal

Angle findingAt least 180° of appositional contact

Absent findingsNo synechiae or optic nerve abnormalities

Primary angle-closure glaucoma (PACG)

Underlying angle statusPrimary angle closure

Optic nerve findingGlaucomatous optic neuropathy

Alternative findingVisual field defects

Acute angle closure (AAC)

IOPAcutely elevated above 30 mm Hg

Associated findingsCharacteristic anterior segment findings

ConditionAcute angle closure

OAG

AbbreviationOAG

MeaningOpen-angle glaucoma

Evidence populationAdults with OAG, including primary open-angle glaucoma and other open-angle subtypes

POAG

AbbreviationPOAG

MeaningPrimary open-angle glaucoma

Disease range discussedMild to moderate disease in comparative Streamline and OMNI studies

IOPR

AbbreviationIOPR

MeaningIntraocular pressure reduction from baseline

Measurement basisChange in IOP relative to the pretreatment baseline

ABiC

AbbreviationABiC

ExpansionAb interno canaloplasty

Procedure contextDescribed with the OMNI device before trabeculotomy

KDB goniotomy

ProcedureKahook Dual Blade goniotomy

DeviceKahook Dual Blade

Common contextGenerally discussed when combined with phacoemulsification

GATT

AbbreviationGATT

ExpansionGonioscopy-assisted transluminal trabeculotomy

Clinical contextEvaluated in medically uncontrolled secondary open-angle glaucoma after silicone oil removal

Trabectome

PlatformElectrosurgical platform with a single-use handpiece, irrigation/aspiration unit, and high-frequency generator

MechanismAblates the trabecular meshwork along Schlemm canal

AccessPerformed through a small corneal incision; alone or with cataract surgery

Ab interno trabecular bypass surgery

ProcedureAb interno trabecular bypass surgery

TechniqueUses the Trabectome procedure

Indication contextTreats open-angle glaucoma

GATT

AbbreviationGATT

ExpansionGonioscopy-assisted transluminal trabeculotomy

Evidence contextAn ab interno trabeculotomy evaluated for various forms of open-angle and secondary glaucoma

KDB goniotomy

Procedure typeKahook Dual Blade excisional goniotomy or ab interno trabeculectomy

Stand-alone useMay be performed as a stand-alone procedure

Combined useMay be combined with cataract surgery

MIGS

MeaningMinimally invasive glaucoma surgery

Trabecular targetProcedures may target the trabecular meshwork or Schlemm canal

Other target spacesProcedures may target the subconjunctival space and are commonly combined with phacoemulsification

Aqueous shunts

Device typeGlaucoma drainage devices

ReservoirExtraocular reservoir

Reservoir typesValved or nonvalved

Aqueous shunt

ImplantGlaucoma implant with an extraocular reservoir

TypesValved and nonvalved devices

PurposeLowers intraocular pressure

ELIOS

Laser308-nm excimer laser

CombinationUsed with phacoemulsification

EffectCreates 10 microchannels in the trabecular region

FLIGHT

ExpansionFemtosecond laser, image-guided, high-precision trabeculotomy

Laser typeFemtosecond laser

Guidance and precisionImage-guided and high precision

Glaucoma Surgical Treatments (for North Carolina Only)

Sign up for UnitedHealthcare Policy CSNCT0443.05 alerts

Covered and Noncovered Glaucoma Procedures

Related Codes, Devices, and Clinical Identifiers

Documentation and Review Considerations

Glaucoma Overview

Clinical Terms and Procedure Definitions