CG-SURG-100 Laser Trabeculoplasty and Laser Peripheral Iridotomy

This policy addresses laser trabeculoplasty and laser peripheral iridotomy (LPI) for glaucoma management. Laser trabeculoplasty is medically necessary as initial treatment for newly diagnosed glaucoma, for medically refractory glaucoma, or when patients are at high risk for nonadherence/intolerance to topical therapy; LPI is medically necessary for primary angle closure or angle-closure glaucoma to relieve pupillary block and prevent acute attacks. Both procedures are not medically necessary when these criteria are not met, and LPI is specifically not covered for primary angle-closure suspects (PACS).

"Laser trabeculoplasty is consideredmedically necessaryfor glaucoma in the following situations:"

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