372 Form

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Medical Policy Viscocanalostomy and Canaloplasty Table of Contents • Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History

Policy Number: 372

BCBSA Reference Number: 9.03.26 (For Plan internal use only) NCD/LCD: N/A Related Policies
None Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity
Medicare HMO BlueSM and Medicare PPO BlueSM Members

Canaloplasty may be considered MEDICALLY NECESSARY as a method to reduce intraocular pressure (IOP) in individuals with chronic primary open-angle glaucoma under the following conditions: • Medical therapy has failed to adequately control IOP, AND • The individual is not a candidate for any other IOP-lowering procedure (eg, trabeculectomy or glaucoma drainage implant) due to a high risk for complications.

Canaloplasty is considered INVESTIGATIONAL under all other conditions, including angle-closure glaucoma.

Viscocanalostomy is considered INVESTIGATIONAL.

Prior Authorization Information
Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for situations where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) Prior authorization is not required. Commercial PPO and Indemnity Prior authorization is not required. Medicare HMO BlueSM Prior authorization is not required.

2 Medicare PPO BlueSM Prior authorization is not required.

CPT Codes / HCPCS Codes / ICD Codes Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

The following codes are included below for informational purposes only; this is not an all-inclusive list.

The above medical necessity criteria MUST be met for the following codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue and Medicare PPO Blue:

CPT Codes CPT Codes: Description 66174 Transluminal dilation of aqueous outflow canal (eg, canaloplasty); without retention of device or stent 66175 Transluminal dilation of aqueous outflow canal (eg, canaloplasty); with retention of device or stent

The following ICD Diagnosis Codes are considered medically necessary when submitted with the CPT codes above if medical necessity criteria are met: ICD-10 Diagnosis Codes ICD-10-CM Diagnosis codes: Code Description H40.1110 Primary open-angle glaucoma, right eye, stage unspecified H40.1111 Primary open-angle glaucoma, right eye, mild stage H40.1112 Primary open-angle glaucoma, right eye, moderate stage H40.1113 Primary open-angle glaucoma, right eye, severe stage H40.1114 Primary open-angle glaucoma, right eye, indeterminate stage H40.1120 Primary open-angle glaucoma, left eye, stage unspecified H40.1121 Primary open-angle glaucoma, left eye, mild stage H40.1122 Primary open-angle glaucoma, left eye, moderate stage H40.1123 Primary open-angle glaucoma, left eye, severe stage H40.1124 Primary open-angle glaucoma, left eye, indeterminate stage H40.1130 Primary open-angle glaucoma, bilateral, stage unspecified H40.1131 Primary open-angle glaucoma, bilateral, mild stage H40.1132 Primary open-angle glaucoma, bilateral, moderate stage H40.1133 Primary open-angle glaucoma, bilateral, severe stage H40.1134 Primary open-angle glaucoma, bilateral, indeterminate stage H40.1190 Primary open-angle glaucoma, unspecified eye, stage unspecified H40.1191 Primary open-angle glaucoma, unspecified eye, mild stage H40.1192 Primary open-angle glaucoma, unspecified eye, moderate stage H40.1193 Primary open-angle glaucoma, unspecified eye, severe stage H40.1194 Primary open-angle glaucoma, unspecified eye, indeterminate stage

3 Description Glaucoma Glaucoma is the leading cause of irreversible blindness worldwide and is characterized by elevated intraocular pressure (IOP). In 2020, glaucoma affected approximately 52.7 million individuals globally, with a projected increase to 79.8 million in 2040.1, Glaucoma has been reported to be 7 times more likely to cause blindness and 15 times more likely to cause visual impairment in Black individuals as compared to White individuals. In the U.S. in 2010, Black individuals had the highest prevalence rate of primary open angle glaucoma at 3.4% compared to 1.7% among White individuals.

Impaired Aqueous Humor Drainage In the primary (conventional) outflow pathway from the eye, aqueous humor passes through the trabecular meshwork, enters a space lined with endothelial cells (Schlemm canal), drains into collector channels, and then into the aqueous veins. Increases in resistance in the trabecular meshwork and/or the inner wall of Schlemm canal can disrupt the balance of aqueous humor inflow and outflow, resulting in an increase in intraocular pressure and glaucoma risk.

Treatment Surgical intervention may be indicated in patients with glaucoma when the target intraocular pressure cannot be reached pharmacologically. Trabeculectomy (guarded filtration surgery) is the most established surgical procedure for glaucoma, allowing aqueous humor to directly enter the subconjunctival space. This procedure creates a subconjunctival reservoir with a filtering “bleb” on the eye, which can effectively reduce intraocular pressure, but is associated with numerous and sometimes sight-threatening complications (eg, leaks, hypotony, choroidal effusions and hemorrhages, hyphemas or bleb-related endophthalmitis) and long-term failure. Other surgical procedures (not addressed herein) include trabecular laser ablation and deep sclerectomy, which removes the outer wall of Schlemm canal and excises deep sclera and peripheral cornea.

More recently, the Trabectome™, an electrocautery device with irrigation and aspiration, has been used to selectively ablate the trabecular meshwork and inner wall of Schlemm canal without external access or creation of a subconjunctival bleb. Intraocular pressure with this ab interno procedure is typically higher than the pressure achieved with standard filtering trabeculectomy. Aqueous shunts may also be placed to facilitate drainage of aqueous humor. Complications from anterior chamber shunts include corneal endothelial failure and erosion of the overlying conjunctiva.

Alternative nonpenetrating methods being evaluated to treat glaucoma are viscocanalostomy and canaloplasty. Viscocanalostomy is a variant of deep sclerectomy and unroofs and dilates the Schlemm canal without penetrating the trabecular meshwork or anterior chamber. A high-viscosity viscoelastic solution (eg, sodium hyaluronate) is used to open the canal and create a passage from the canal to a scleral reservoir. It has been proposed that viscocanalostomy may lower intraocular pressure while avoiding bleb-related complications.

Canaloplasty, which evolved from viscocanalostomy, involves dilation and tension of the Schlemm canal with a suture loop between the inner wall of the canal and the trabecular meshwork. This procedure uses the iTrack™ illuminated microcatheter to access and dilate the length of the Schlemm canal and to pass the suture loop through the canal. An important difference between viscocanalostomy and canaloplasty is that canaloplasty attempts to open the entire length of the Schlemm canal, rather than one section. The OMNI® Surgical System also dilates the Schlemm canal and collector channels. Both ab externo (using an external approach) and ab interno (using an internal approach) canaloplasty techniques are used, with or without trabeculotomy. Ab interno canaloplasty (ABiC) is considered a minimally invasive glaucoma surgery (MIGS) but ab externo canaloplasty is not.2, Other MIGS, such as gonioscopy-assisted transluminal trabeculotomy (GATT) are not discussed in this policy.

Because aqueous humor outflow is pressure-dependent, the pressure in the reservoir and venous system is critical for reaching the target intraocular pressure. Therefore, some procedures may not reduce intraocular pressure below the pressure of the distal outflow system used (eg, <15 mm Hg), and are not

4 indicated for patients for whom very low intraocular pressure is desired (eg, those with advanced glaucoma).

Summary Glaucoma surgery is intended to reduce intraocular pressure when the target intraocular pressure cannot be reached with medications. Due to complications with established surgical approaches (eg, trabeculectomy), alternative surgical treatments (eg, transluminal dilation by viscocanalostomy or canaloplasty) are being evaluated for individuals with glaucoma.

Summary of Evidence For individuals who have open-angle glaucoma who have failed medical therapy who receive viscocanalostomy, the evidence includes small randomized controlled trials (RCTs) comparing viscocanalostomy with trabeculectomy. Relevant outcomes are symptoms, morbid events, quality of life, and medication use. Meta-analysis of these trials has indicated that trabeculectomy has a greater intraocular pressure lowering effect than viscocanalostomy. Reduction in intraocular pressure was greater with canaloplasty than viscocanalostomy in a small within-subject comparison. Viscocanalostomy has not been shown to be as good as or better than established alternatives. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have open-angle glaucoma who have failed medical therapy who receive canaloplasty, the evidence includes several systematic reviews of observational trials, several RCTs, a comparative effectiveness review, non-randomized comparative studies, and numerous case series. Relevant outcomes are symptoms, morbid events, quality of life, and medication use. The systematic reviews and one RCT found greater efficacy with trabeculectomy than with canaloplasty. However, higher complication rates were also observed for trabeculectomy. Nonrandomized comparative studies have generally reported higher success rates with canaloplasty compared to other procedures but not all of the differences were statistically significant. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Policy History Date Action 5/2026 Annual policy review. Policy updated with literature review through January 17, 2026; references added. Policy statements unchanged.
5/2025 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 5/2024 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 5/2023 Annual policy review. Minor editorial refinements made to policy statements; intent unchanged. 5/2022 Annual policy review. Not medically necessary policy statement changed to Investigational for policy standardization purposes. Policy intent unchanged. 5/2021 BCBSA National medical policy review. Description, summary, and references updated. Policy statements unchanged. 5/2020 BCBSA National medical policy review. Description, summary, and references updated. Policy statements unchanged. 4/2019 BCBSA National medical policy review. Description, summary, and references updated. Policy statements unchanged. 5/2018 New references added from BCBSA National medical policy. Background and summary clarified. Prior Authorization Information reformatted.
5/2017 BCBSA National medical policy review. Policy statement on viscocanalostomy clarified to state that it is not medically necessary.
10/2016 Clarified coding information. 4/2016 New references added from BCBSA National medical policy. 11/2015 New references added from BCBSA National medical policy.

5 6/2014 Updated Coding section with ICD10 procedure and diagnosis codes. Effective 10/2015. 11/2013 Removed CPT code 66180 as it does not meet the intent of the policy. 9/1/12 New policy describing ongoing coverage and non-coverage.
Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines

References

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56. National Institute for Health and Care Excellence (NICE). Glaucoma: diagnosis and management [NG81]. 2022; https://www.nice.org.uk/guidance/NG81. Accessed January 18, 2026.
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