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Glaucoma surgery is intended to reduce intraocular pressure (IOP) when the target IOP cannot be reached with medications. Due to complications with established surgical approaches (eg, trabeculectomy), a variety of shunts are being evaluated as alternative surgical treatments for patients with inadequately controlled glaucoma. Microstents are also being evaluated in patients with mild-to-moderate open-angle glaucoma currently treated with ocular hypotensive medication.
Surgical procedures for glaucoma aim to reduce intraocular pressure (IOP) resulting from impaired aqueous humor drainage in the trabecular meshwork and/or Schlemm canal. In the primary (conventional) outflow pathway from the eye, aqueous humor passes through the trabecular meshwork, enters a space lined with endothelial cells (Schlemm canal), drains into collector channels, and then into the aqueous veins. Increases in resistance in the trabecular meshwork and/or the inner wall of the Schlemm canal can disrupt the balance of aqueous humor inflow and outflow, resulting in an increase in IOP and glaucoma risk.
Surgical intervention may be indicated in patients with glaucoma when the target IOP cannot be reached pharmacologically. Trabeculectomy (guarded filtration surgery) is the most established surgical procedure for glaucoma, allowing aqueous humor to directly enter the subconjunctival space. This procedure creates a subconjunctival reservoir, which can effectively reduce IOP, but commonly results in filtering “blebs” on the eye, and is associated with numerous complications (e.g., leaks; bleb-related endophthalmitis) and long-term failure. Other surgical procedures (not addressed in this policy) include trabecular laser ablation, deep sclerectomy (which removes the outer wall of Schlemm canal and excises deep sclera and peripheral cornea), and viscocanalostomy (which unroofs and dilates the Schlemm canal without penetrating the trabecular meshwork or anterior chamber).
More recently, the Trabectome, an electrocautery device with irrigation and aspiration, has been used to selectively ablate the trabecular meshwork and inner wall of the Schlemm canal without external access or creation of a subconjunctival bleb. IOP with this ab interno procedure is typically higher than the pressure achieved with standard filtering trabeculectomy. Canaloplasty involves dilation and tension of the Schlemm canal with a suture loop between the inner wall of the canal and the trabecular meshwork. This ab externo procedure uses the iTrack™ illuminated microcatheter (iScience Interventional) to access and dilate the entire length of the Schlemm canal and to pass the suture loop through the canal.
Aqueous shunts may also be placed in the anterior or posterior chamber to facilitate drainage of aqueous humor. Established shunts include the Ahmed (New World Medical), Baerveldt (Advanced Medical Optics), Molteno (IOP), Ex-Press mini-shunt (Alcon); and the SOLX DeepLight Gold Micro-Shunt (SOLX), which shunt aqueous humor between the anterior chamber and the suprachoroidal space. These devices differ by explant surface areas, shape, plate thickness, the presence or absence of a valve, and details of surgical installation. Generally, the risk of hypotony (low pressure) is reduced with aqueous shunts in comparison with trabeculectomy, but IOP outcomes are worse than after standard guarded filtration surgery. Complications of anterior chamber shunts include corneal endothelial failure and erosion of the overlying conjunctiva. The risk of postoperative infection is lower with shunts than with trabeculectomy, and failure rates are similar (approximately 10% of devices fail annually). The primary indication for aqueous shunts is for failed medical or surgical therapy, although some ophthalmologists have advocated their use as a primary surgical intervention, particularly for selected conditions such as congenital glaucoma, trauma, chemical burn, or pemphigoid.
Aqueous stents are being developed as minimally penetrating methods to drain aqueous humor from the anterior chamber into the Schlemm canal or the suprachoroidal space. They include the iStent (Glaukos), which is a 1-mm long stent inserted into the end of the Schlemm canal by an internal approach through the cornea and anterior chamber; the second-generation iStent inject, the third-generation iStent supra, which is designed for ab interno implantation into the suprachoroidal space; and the CyPass (Transcend Medical) suprachoroidal stent.
Because aqueous humor outflow is pressure-dependent, the pressure in the reservoir and venous system is critical for reaching the target IOP. Therefore, some devices may be unable to reduce IOP below the pressure of the distal outflow system used (e.g., below 15 mm Hg) and are not indicated for patients for whom very low IOP is desired (e.g., those with advanced glaucoma). It has been proposed that stents such as the iStent, Cypass, and Hydrus Microstent may be useful in patients with early-stage glaucoma to reduce the burden of medications and problems with compliance. One area of investigation is patients with glaucoma who require cataract surgery. An advantage of ab interno shunts is that they may be inserted into the same incision and at the same time as cataract surgery. In addition, most devices do not preclude subsequent trabeculectomy if needed. It may also be possible to insert more than one shunt to achieve the desired IOP. Therefore, health outcomes of interest are the IOP achieved, reduction in medication use, ability to convert to trabeculectomy, complications, and device durability.
The first-generation Ahmed™ (New World Medical), Baerveldt® (Advanced Medical Optics), Krupin (Eagle Vision), and Molteno® (Molteno Ophthalmic) aqueous shunts were cleared for marketing by the U.S. Food and Drug Administration (FDA) through the 510(k) process between 1989 and 1993; modified Ahmed and Molteno devices were cleared in 2006. They are indicated for use “in patients with intractable glaucoma to reduce intraocular pressure where medical and conventional surgical treatments have failed.” The AquaFlow™ Collagen Glaucoma Drainage Device was approved by the FDA through the premarket approval process for the maintenance of the subscleral space following non-penetrating deep sclerectomy. In 2003, the EX-PRESS® Mini Glaucoma Shunt was cleared for marketing by the FDA through the 510(k) process. The Ex-PRESS® shunt is placed under a partial thickness scleral flap and transports aqueous fluid from the anterior chamber of the eye into a conjunctival filtering bleb.
In 2012, the iStent® Trabecular Micro-Bypass Stent (Glaukos) was approved by the FDA through the premarket approval process for use in conjunction with cataract surgery for the reduction of IOP in adult patients with mild-to-moderate open-angle glaucoma currently treated with ocular hypotensive medication.
The labeling describes the following precautions:
Note: Use of the iStent® has subsequently been reported for many of the circumstances or conditions listed above; most of the publications are case series.
Related policies include Ophthalmologic Techniques of Evaluating Glaucoma and Transciliary Fistulization for the Treatment of Glaucoma.
Insertion of aqueous shunts approved by the U.S. Food and Drug Administration (FDA) may be considered medically necessary as a method to reduce intraocular pressure in patients with glaucoma where medical therapy has failed to adequately control intraocular pressure.
Use of an aqueous shunt for all other conditions, including in patients with glaucoma when intraocular pressure is adequately controlled by medications, is considered investigational.
Implantation of a single FDA-approved microstent in conjunction with cataract surgery may be considered medically necessary in patients with mild-to-moderate open-angle glaucoma currently treated with ocular hypotensive medication.
Use of a microstent for all other conditions is considered investigational.
POLICY EXCEPTIONSFederal Employee Program (FEP) may dictate that all FDA-approved devices, drugs or biologics may not be considered investigational and thus these devices may be assessed only on the basis of their medical necessity.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Shunts and stents are only able to reduce intraocular pressure (IOP) to the mid-teens and may be inadequate when very low IOP is needed to reduce glaucoma damage.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Nervous/Mental Conditions, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
7/24/2008: Policy added
11/20/2008: Approved by Medical Policy Advisory Committee (MPAC)
05/13/2010: Policy title changed from "Emerging Surgical Treatments for Glaucoma" to "Aqueous Shunts and Devices for Glaucoma." Policy description updated regarding treatment approaches and FDA status of devices. Policy statement revised to indicate that insertion of aqueous shunts approved by the U.S. Food and Drug Administration (FDA) may be considered medically necessary as a method to reduce intraocular pressure in patients with glaucoma where medical therapy has failed to adequately control intraocular pressure. Moved HCPCS codes 0191T and 0192T from non-covered to covered. All other conditions and canaloplasty remain investigational. FEP verbiage added to the Policy Exceptions section.
03/07/2011: Added new CPT codes 0253T and 66175 to the Code Reference section.
08/11/2011: Policy statement revised to indicate that canaloplasty may be considered medically necessary under certain conditions. Moved CPT code 66175 from non-covered to covered.
01/09/2013: In the policy title, changed "Devices" to "Stents." Added the following investigational policy statement: Use of a micro-stent is considered investigational.
04/24/2013: Added ICD-9 codes 365.00-365.9 and 12.67 to the Code Reference section.
01/22/2014: Policy statement revised to state that implantation of a single FDA-approved microstent in conjunction with cataract surgery may be considered medically necessary in patients with mild to moderate open-angle glaucoma currently treated with ocular hypotensive medication. Added the following new 2014 CPT code(s) to the Code Reference section: 66183.
10/17/2014: Policy reviewed; description updated regarding devices. Policy statement unchanged. Policy guidelines updated to state that shunts and stents are only able to reduce intraocular pressure (IOP) to the mid-teens and may be inadequate when very low IOP is needed to reduce glaucoma damage. Removed deleted CPT code 0192T from the Code Reference section.
12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 0191T and 0253T. Effective 01/01/2015. Added the following new 2015 CPT codes: 0376T, 66179, and 66184.
08/21/2015: Code Reference section updated for ICD-10.
11/10/2015: Policy description updated regarding devices. Policy statements unchanged. Policy guidelines updated to add medically necessary and investigative definitions.
04/25/2016: Policy description updated. Policy statements unchanged.
05/27/2016: Policy number A.9.03.21 added.
09/09/2016: Code Reference section updated to make correction: ICD-10 diagnosis code H40.1 should be H40.10X0.
12/30/2016: Code Reference section updated to add new 2017 CPT codes 0449T and 0450T.
SOURCE(S)Blue Cross and Blue Shield Association Policy # 9.03.21
This may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.