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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), alternative surgical treatments (eg, transluminal dilation by viscocanalostomy and canaloplasty) are being evaluated for patients with glaucoma.
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 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 with a filtering “bleb” on the eye, which can effectively reduce IOP, but is associated with numerous and sometimes sight-threatening complications (e.g., leaks, hypotony, choroidal effusions and hemorrhages, hyphemas or bleb-related endophthalmitis) and long-term failure. Other surgical procedures (not addressed in this policy) include trabecular laser ablation and deep sclerectomy, which removes the outer wall of Schlemm canal and excises deep sclera and peripheral cornea.
More recently the Trabectome™, an electrocautery device with irrigation and aspiration, has been used to selectively ablate the trabecular meshwork and inner wall of 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. Aqueous shunts may also be placed to facilitate drainage of aqueous humor (see Aqueous Shunts and Stents for Glaucoma medical policy). Complications of anterior chamber shunts include corneal endothelial failure and erosion of the overlying conjunctiva.
Alternative nonpenetrating methods that are being evaluated for glaucoma are viscocanalostomy and canaloplasty. Viscocanalostomy is a variant of deep sclerectomy and unroofs and dilates Schlemm canal without penetrating the trabecular meshwork or anterior chamber. A high-viscosity viscoelastic solution, (eg, sodium hyaluronate) is used to open the canal and create a passage from the canal to a scleral reservoir. It has been proposed that viscocanalostomy may lower IOP while avoiding bleb-related complications.
Canaloplasty, which evolved from viscocanalostomy, involves dilation and tension of 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 length of Schlemm canal and to pass the suture loop through the canal. An important difference between viscocanalostomy and canaloplasty is that canaloplasty attempts to open the entire length of Schlemm canal, rather than one section of it.
Because aqueous humor outflow is pressure-dependent, the pressure in the reservoir and venous system is critical for reaching the target IOP. Therefore, some procedures may not be able 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). Health outcomes of interest are the IOP achieved, reduction in medications, ability to convert to trabeculectomy if the procedure is unsuccessful, complications, and durability of the procedure.
The iTrack (iScience Interventional) received 510(k) marketing clearance from the U.S. Food and Drug Administration (FDA) through the 510(k) process in 2004 as a surgical ophthalmic microcannula that is indicated for the general purpose of “fluid infusion and aspiration, as well as illumination, during surgery.” In 2008, the iTrack received FDA-clearance for the indication of “catheterization and viscodilation of [the] Schlemm canal to reduce intraocular pressure in adult patients with open angle glaucoma.”
POLICYCanaloplasty may be considered medically necessary as a method to reduce intraocular pressure in patients with chronic primary open-angle glaucoma under the following conditions:
Canaloplasty is considered investigational under all other conditions, including angle-closure glaucoma.
Viscocanalostomy 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.
Tensioning devices are only able to reduce 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.
POLICY HISTORY11/17/2011: Approved by Medical Policy Advisory Committee.
11/30/2012: Policy reviewed; no changes.
11/15/2013: Policy reviewed; no changes.
09/26/2014: Policy reviewed. Policy guidelines updated regarding tensioning devices.
08/14/2015: Medical policy revised to add ICD-10 codes.
10/28/2015: Policy reviewed. Policy statements unchanged. Policy guidelines updated to add medically necessary and investigative definitions.
04/25/2016: Policy reviewed; no changes.
05/27/2016: Policy number A.9.03.26 added.
09/30/2016: Code Reference section updated to add new ICD-10 diagnosis codes H40.1110 - H40.1194.
SOURCE(S)Blue Cross Blue Shield Association policy # 9.03.26
CODE REFERENCEThis 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.
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