Medical Policy
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, 66982, 66983, 66984, 66987, 66988
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, H40.1121, H40.1122, H40.1131 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)

66982            Extracapsular cataract removal w/insertion of intraocular lens prosthesis

                      (1-stage procedure), manual or mechanical technique, complex, without

                      endoscopic cyclophotocoagulation

66983            Intracapsular cataract extraction w/insertion of intraocular lens prosthesis

                      (1 stage procedure)

66984            Extracapsular cataract removal w/insertion of intraocular lens prosthesis

                      (1 stage procedure), manual or mechanical technique; without endoscopic

                      cyclophotocoagulation

66987            Extracapsular cataract removal w/insertion of intraocular lens prosthesis

                      (1-stage procedure), manual or mechanical technique, complex;

                      w/endoscopic cyclophotocoagulation

66988            Extracapsular cataract removal w/insertion of intraocular lens prosthesis

                      (1 stage procedure), manual or mechanical technique; w/endoscopic

                      cyclophotocoagulation
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.

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.