Anthem Blue Cross Connecticut SURG.00095 Viscocanalostomy and Canaloplasty Form

This document addresses viscocanalostomy and canaloplasty. Viscocanalostomy and canaloplasty are forms of non-penetrating glaucoma surgery. They are proposed as alternatives to trabeculectomy, the traditional surgical treatment of primary open-angle glaucoma (POAG).

Note: Please see the following related document for additional information:

• SURG.00103 Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)

Position Statement

Medically Necessary:

Canaloplasty is considered medically necessary for the treatment of mild to moderate primary open-angle glaucoma (POAG).

Investigational and Not Medically Necessary:

Viscocanalostomy is considered investigational and not medically necessary for all indications, including but not limited to the treatment of primary open-angle glaucoma (POAG).

Canaloplasty is considered investigational and not medically necessary for all other indications.