Anthem Blue Cross Connecticut CG-SURG-100 Laser Trabeculoplasty and Laser Peripheral Iridotomy Form

This document addresses the use of laser trabeculoplasty and laser peripheral iridotomy.

Note: For information about other proposed treatments of glaucoma see:

• MED.00118 Continuous Monitoring of Intraocular Pressure
• SURG.00095 Viscocanalostomy and Canaloplasty
• SURG.00103 Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)

Clinical Indications

Medically Necessary:

Laser trabeculoplasty is considered medically necessary for glaucoma in the following situations:

• As initial treatment of newly diagnosed glaucoma; or
• As treatment for medically refractory glaucoma; or
• As treatment for individuals who are at high risk for nonadherence to medical therapy (for example, those who cannot tolerate medications or who are noncompliant with medications due to memory problems or have difficulty with instillation).

Laser peripheral iridotomy is considered medically necessary in the following situations:

• Individuals with primary angle-closure or primary angle-closure glaucoma.

Not Medically Necessary:

Laser trabeculoplasty is considered not medically necessary when the above criteria are not met and for all other indications.

Laser peripheral iridotomy is considered not medically necessary when the above criteria are not met and for all other indications.