L8612 — Aqueous shunt
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Diagnosis and patient age consistent with the covered indication (e.g., pediatric glaucoma for patients <= 18 years; adult OAG with cataract for adults >= 19 years when the procedure is to be performed in combination with cataract surgery). Clinical evidence of glaucoma consistent with definitions used in the policy: evidence of optic nerve damage (optic disc or RNFL structural abnormalities) and/or reliable and reproducible visual field abnormality (standard automated perimetry), as applicable. Severity staging documentation as appropriate (mild, moderate, severe, indeterminate) based on optic disc/RNFL/imaging and SAP visual field results. Documentation that the adult patient has both visually significant cataract and mild to moderate OAG and is 'currently being treated with ocular hypotensive medication' when seeking coverage for the indicated combined procedures (e.g., iStent, Hydrus, ab interno canaloplasty, combined canaloplasty + trabeculotomy). For glaucoma drainage devices (GDDs): documentation that medical and/or prior surgical treatments have failed or are inappropriate (clinical rationale and prior treatment records), consistent with 'refractory glaucoma' indication. Preoperative clinical data such as baseline IOP measurements (e.g., Goldmann applanation tonometry), glaucoma medication regimen, gonioscopy findings, and relevant ocular imaging (OCT RNFL, optic disc photos) to support the diagnosis and necessity of the procedure. Operative note and device details (device type/model, approach — ab interno vs ab externo, concomitant cataract extraction if applicable) and postoperative follow-up documentation (IOP, medications, complications). Documentation that patient is an adult (age 19 years or more) when applicable (explicit age criterion stated for certain procedures) Evidence that the procedure will be performed in combination with cataract surgery when required by the covered indication (e.g., for goniotomy/trabeculotomy/canaloplasty coverage when combined with cataract surgery) Clinical documentation of diagnosis: mild to moderate open-angle glaucoma (OAG) and concurrent cataract when coverage is sought under the combined-procedure indication Documentation that the patient is 'currently being treated with ocular hypotensive medication' when required by the covered indication For glaucoma drainage devices, documentation that glaucoma is 'refractory' and that 'medical and conventional surgical treatments have failed' or are inappropriate Because the policy directs checking member-specific benefit documents, include evidence of plan applicability (member-specific benefit plan) — i.e., confirmation that the member's plan allows the service
Key Coverage Criteria
- Goniotomy or trabeculotomy for pediatric glaucoma (age 18 years or less) Goniotomy, trabeculotomy, canaloplasty (ab interno), or combined canaloplasty (ab interno) and trabeculotomy (e.g., OMNI® Surgical System, Streamline Surgical System) for adults (age 19 years or more) when used in combination with cataract surgery for treating mild to moderate open-angle glaucoma (OAG) and cataract in adults currently being treated with ocular hypotensive medication iStent®, iStent inject®, or Hydrus® Micro [...]
- 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
AMBETTER-CP.MP.107 — Durable Medical Equipment and Orthotics and Prosthetics Guidelines
HUMANA-GLAUCOMA-SURGICAL-TREATMENTS-MA — Glaucoma Surgical Treatments - Medicare Advantage
AETNA-CPB-0484 — Glaucoma Surgery
UHC-POL-glaucoma-surgical-treatments — Glaucoma Surgical Treatments
UMR-POL-UMR-glaucoma-surgical-treatments — Glaucoma Surgical Treatments
Related Codes
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