Coverage Policies

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If not specified in a QualChoice coverage policy (Benefit Interpretation), QualChoice follows care guidelines published by MCG Health.

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INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 03/01/2018 Title: Minimally Invasive Glaucoma Surgery (MIGS)
Revision Date: 01/01/2020 Document: BI572:00
CPT Code(s): C1783, 0191T, 0376T
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply. 

1.    The iStent is an example of devices that can be implanted in the eye to help drain excess fluid buildup associated with Glaucoma (increased fluid pressure in the eye). These devices can be inserted at the time of cataract surgery in patients who are also being treated for glaucoma.

2.    Insertion of these devices requires preauthorization.  It is not considered medically necessary and will not be covered if your glaucoma is well controlled with two or less medications.


Medical Statement

iStent (HCPCS code C1783) and iStent insertion (CPT code 0191T) requires PA.

a)    These are considered medically necessary if billed concurrently with cataract surgery (66982, 66983, 66984, 66987 or 66988) and a diagnosis of mild to moderate primary open angle glaucoma (H40.1111, H40.1112, H40.121, H40.1122, H40.131 or H40.1132) in which intraocular pressure is not well controlled (IOP >21 mm Hg) with two medications.

 

Codes Used In This BI:

 

C1783            Ocular implant, aqueous drainage assist device

0191T             Insertion of ant segment aqueous drainage device

0376T             Insertion of ant segment aqueous drainage device (each additional)

0474T             Insertion of ant segment aqueous drainage device with intraocular reservoir (CyPass Micro-Stent)


Limits

1)    Not covered if IOP ≤ 21 on two (or fewer) medications.

2)    Medicare does not place any restrictions on coverage relative to IOP control on medications. If Medicare is the primary payer (and QualChoice secondary), Medicare payment rules apply.


Background

1)    The ability to control intraocular pressure (IOP) without medications in a patient with open-angle glaucoma through the use of intraocular implants is convenient but may not be medically necessary. Clearly it is not medically necessary if IOP is in the normal range on medications.

2)    There is an argument that, by avoiding long-term medication costs, the use of expensive intraocular implants may actually be more cost–effective in the long run.  With the availability of several inexpensive (generic) eye drops, the argument in favor intraocular implants being cost-effective is much less credible. 

3)    At this time there is insufficient research supporting significant added benefits of routinely implanting more than one aqueous drainage device per eye at the time of glaucoma surgery.


Reference

1)    Spiegel D, et al. Coexistent primary open-angle glaucoma, and cataract: Preliminary analysis of treatment by cataract surgery and the iStent trabecular micro-bypass stent. Advances in Therapy. 2008; 25(5):453-664.

2)    Buchacra O, et al. One-year analysis of the iStent trabecular micro bypass in secondary glaucoma. Clin Ophthalmol. 2011; 5:321-326.

3)    Arriola-Villalobos P, et al. combined iStent trabecular micro-bypass stent implantation and phacoemulsification for coexistent open-angle glaucoma and cataract: a long-term study. Br J Ophthalmol. 2012; 96(5):645-649.

4)    Vold S, et al. Two-year COMPASS trial results: supraciliary microstenting with phacoemulsification in patients with open angle glaucoma and cataracts. Ophthalmology. 2016; 123(10):2103-2112.

5)      Hoeh H, et al. Initial experience with the CyPass Micro-Stent: safety and surgical outcomes of a novel supraciliary microstent. J Glaucoma. 2016; 25(1):106-112.

6)     Katz LJ, Erb C, et al. Long-term titrated IOP control with one, two, or three trabecular micro-bypass stents in open-angle glaucoma subjects on topical hypotensive medication: 42-month outcomes. Clinical Ophthalmology. 2018; 12:255-262.


Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.