L8612, Aqueous shunt
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Pre-operative documentation of diagnosis (e.g., OAG/POAG, OHT, refractory glaucoma) and indication for surgery (e.g., inadequate IOP control on medical therapy, need for surgical intervention).
- Pre- and post-operative intraocular pressure (IOP) measurements, including medicated IOP and, where performed, unmedicated/post-washout IOP or mean diurnal IOP (many studies used medicated and post-washout IOPs and mean diurnal IOP as endpoints).
- Record of number and classes of IOP-lowering medications pre- and post-procedure (primary and secondary outcomes in multiple trials include medication-free proportions and medication counts).
- Documentation of prior glaucoma treatments and surgeries (e.g., prior incisional or cilio-ablative surgeries, prior laser procedures, and maximum tolerated medical therapy).
Key Coverage Criteria
- Indication: Covered glaucoma surgical treatments for pediatric and adult patients include goniotomy/trabeculotomy for children; ab interno canaloplasty and/or combined canaloplasty with trabeculotomy for adults; MIGS devices (iStent, iStent inject, Hydrus) with cataract surgery for mild-moderate OAG; glaucoma drainage devices for refractory glaucoma after failed or inappropriate medical/surgical treatments; laser procedures (trabeculoplasty, iridotomy/iridectomy, iridoplasty, ciliary body destru [...]
- Laser trabeculoplasty for treatment of members with refractory primary open-angle glaucoma (POAG) when first-line drugs (e.g., latanoprost or timolol) and second-line drugs (e.g., brimonidine or dorzolamide) have failed to control intra-ocular pressure (IOP).
- FDA‑approved aqueous drainage/shunt implants for treatment of members with refractory primary open‑angle glaucoma when first-line and second-line drugs have failed to control IOP. (Examples listed in policy: Ahmed glaucoma implant; Baerveldt seton; Ex‑PRESS mini glaucoma shunt; Glaucoma pressure regulator; Krupin‑Denver valve implant; Molteno implant; Schocket shunt.)
- Ab interno Kahook Dual Blade trabeculectomy — described as used for primary congenital glaucoma in case reports (Harvey and Schmitz 2020) and discussed as a minimally invasive technique.
- Ab interno supraciliary microstent surgery (e.g., CyPass) — RCT evidence showed superiority combined with phacoemulsification vs phaco alone at 24 months, but long-term safety concerns (endothelial cell loss) led to device withdrawal (Cochrane review summary).
- Non-penetrating deep sclerectomy (NPDS) with intra-scleral implant and adjunctive mitomycin C — used in eyes with uncontrolled glaucoma after DSAEK in small case series (Munoz-Negrete et al. 2015).
6 Active Policies
HUMANA-GLAUCOMA-SURGICAL-TREATMENTS-MA, Glaucoma Surgical Treatments
UHC-POL-glaucoma-surgical-treatments, Glaucoma Surgical Treatments
AETNA-CPB-0484, Glaucoma Surgery
AMBETTER-CP.MP.107, Durable Medical Equipment and Orthotics and Prosthetics Guidelines
UMR-POL-UMR-glaucoma-surgical-treatments, Glaucoma Surgical Treatments
Related Codes
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