Independence is updating our policies on aqueous shunts, microstents,
viscocanalostomy, and canaloplasty for the treatment of glaucoma to reflect a
change in coverage position and clarify billing requirements.
The following policies were posted as Notifications on the Medical Policy
Portal on July 25, 2018, and will go into effect October 22,
2018:
- Commercial: #11.05.16g: Aqueous Shunts, Microstents,
Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
- Medicare Advantage: #MA11.105e: Aqueous Shunts,
Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of
Glaucoma
Change to coverage position
Effective October 22, 2018, the coverage position for
certain uses of aqueous shunts or stents (e.g., XEN? Gel Stent), for
both commercial and Medicare Advantage products, will change from Medically
Necessary to Experimental/Investigational as follows:
- The use of ab interno aqueous stents approved by the U.S. Food and Drug
Administration (FDA) as a method to reduce intraocular pressure in patients
with glaucoma where medical therapy has failed to adequately control
intraocular pressure, is considered experimental/investigational and,
therefore, not covered because the available published peer-reviewed literature
does not support their use in the treatment of illness or injury.
- The use of an ab externo aqueous shunt or ab interno aqueous stent for
other conditions, including individuals with glaucoma when the intraocular
pressure is controlled by medication, is considered
experimental/investigational and, therefore, not covered because the available
published peer-reviewed literature does not support their use in the treatment
of illness or injury.
- The use of more than one ab externo aqueous shunt or ab interno aqueous
stent is considered experimental/investigational and, therefore, not covered,
because the safety and/or effectiveness of this service cannot be established
by review of the available published peer-reviewed literature.
Billing requirements
In addition, we have clarified the billing requirements within these
policies. Claims submitted for implantation of microstents (CPT®
code 0191T or 0474T) on or after October 22, 2018,
must include a diagnosis code for mild-to-moderate open-angle glaucoma
and one of the cataract diagnosis codes listed in Attachment A of the
policies.
For more information
To view the Notifications for these policies, go to the Medical Policy Portal.
Select Accept and Go to Medical Policy Online. Then select
Commercial or Medicare Advantage under Active
Notifications.
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rights reserved. CPT? is a registered trademark of the American
Medical Association.