CG-SURG-118 Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)

This policy addresses intraocular anterior segment aqueous drainage devices without an extraocular reservoir for glaucoma, including the Ex-PRESS Glaucoma Filtration Device, Hydrus Microstent, iStent, and iStent inject. Coverage is medically necessary for Ex-PRESS when treating refractory primary or secondary open-angle glaucoma after failure of medical therapy, and for Hydrus/iStent/iStent inject only when implanted in conjunction with cataract surgery. Insertion of these devices is not covered when these criteria are not met, and the CyPass Micro-Stent System is considered not medically necessary.

"Insertion of the Ex-PRESS Glaucoma Filtration Device is consideredmedically necessarywhen the following criteria are met:"

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