Glaucoma Surgery Form

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Last Reviewed

Original Document

Glaucoma Surgery Proprietary information of EmblemHealth. © 2026 EmblemHealth & Affiliates POLICY NUMBER LAST REVIEW MG.MM.SU.63fC3
January 23, 2026

If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. Identification of selected brand names of devices, tests and procedures in a medical coverage policy is for reference only and is not an endorsement of any one device, test or procedure over another. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication.
EmblemHealth may also use tools developed by third parties, such as the MCG™ Care Guidelines, to assist us in administering health benefits. The MCG™ Care Guidelines are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice. EmblemHealth Services Company, LLC, has adopted this policy in providing management, administrative and other services to EmblemHealth Plan, Inc., EmblemHealth Insurance Company, EmblemHealth Services Company, LLC, and Health Insurance Plan of Greater New York (HIP) related to health benefit plans offered by these entities. All of the aforementioned entities are affiliated companies under common control of EmblemHealth Inc. Definitions Aqueous Humor Clear aqueous fluid, which fills the space between the lens and retina in the anterior chamber of the eye where it flows continuously in and out of the chamber nourishing nearby tissues. The fluid exits the chamber at the open angle, where the cornea and iris meet, and flows through a spongy meshwork drain. Schlemm's Canal Circular canal in the eye that drains aqueous humor from the anterior chamber of the eye into the anterior ciliary veins. Intraocular pressure (IOP) The pressure within the eye, which is maintained by a balance between aqueous fluid secretion and fluid outflow; in glaucoma, defects that interfere with aqueous humor outflow lead to a rise in intraocular pressure resulting in degenerative compromise of optic nerve function known as progressive optic nerve atrophy and vision loss. Glaucoma A group of eye diseases characterized by increased IOP), which causes pathological changes in the optic disk and defects in the field of vision.  Open-angle glaucoma (OAG) — progressive form of glaucoma in which the drainage channel for the aqueous humor, composed of the attachment at the edge of the iris and the junction of the sclera and cornea, remains open, and in which serious vision- reduction occurs (advanced stages of the disease) due to tissue changes along the drainage channel.  Primary open-angle glaucoma (POAG; aka chronic glaucoma) — most common type of glaucoma, which is associated with a build-up of aqueous fluid pressure within the

Page 2 of 14 eye that can lead to visual field loss and optic nerve damage (usually without any associated pain or discomfort). There is no abnormality in the anterior chamber angle; however, the aqueous fluid is unable to flow correctly.  Secondary open-angle glaucoma (SOAG) —open angle glaucoma resulting from other medical conditions (e.g. pseudoexfoliative glaucoma, pigmentary glaucoma) or trauma. The severity of glaucoma damage can be estimated using the following:  Mild — optic nerve abnormalities consistent with glaucoma and a normal visual field as tested with standard automated perimetry  Moderate — optic nerve abnormalities consistent with glaucoma and visual field abnormalities in one hemifield that are not within 5 degrees of fixation as tested with standard automated perimetry  Severe — optic nerve abnormalities consistent with glaucoma and visual field abnormalities in both hemifields and/or loss within 5 degrees of fixation in at least one hemifield as tested with standard automated perimetry Hypotony Abnormally low IOP of intraocular fluid; typically occurs as a complication of an underlying ocular disorder (such as uveitis or following a glaucoma surgery). Aqueous shunts (Aka aqueous drainage devices or glaucoma drainage devices, setons, tube implants and tube shunts) Devices implanted into the eye to create an alternate pathway for aqueous humor drainage from the anterior or posterior eye-chamber to a space between the conjunctiva and the sclera where it is absorbed into the blood, thereby lowering IOP. These devices differ depending on explant surface areas, shape, plate thickness, the presence or absence of a valve and details of surgical installation. Generally, the risk of hypotony is reduced with aqueous shunts in comparison with trabeculectomy, but IOP outcomes are higher than after standard guarded filtration surgery. Other aqueous stents (e.g., microstents) are being developed as minimally penetrating methods to drain aqueous humor from the anterior chamber into Schlemm’s canal or the suprachoroidal space. These include the iStent® (Glaukos), which is a 1-mm long stent inserted into the end of Schlemm’s canal by an internal approach through the cornea and anterior chamber; and the third generation iStent supra®, which is designed for ab interno implantation into the suprachoroidal space. An advantage of ab interno shunts is that they may be inserted into the same incision and at the same time as cataract surgery. In addition, most devices do not preclude subsequent trabeculectomy if needed. It may also be possible to insert more than one shunt to achieve the desired IOP. (See Limitations/Exclusions) Trabeculectomy A surgical filtration procedure in which a portion of the trabecular meshwork is surgically removed through a superficial flap of sclera to lower the IOP by creating an alternate pathway for the aqueous fluid to flow from the anterior chamber to a bleb created in the subconjunctival space; this is currently considered the gold standard treatment for glaucoma that is refractory to medical management. Guideline A. Laser trabeculoplasty, trabeculectomy or FDA-approved aqueous drainage/shunt implants* are considered medically necessary for the treatment of refractory open-angle glaucoma when there is intolerance, contraindication or failure of topical/oral medication*** to control IOP. (Note: Goniotomy requests will be case-by-case reviewed)

Antimetabolites such as 5‐Fluorouracil (5‐FU) may be considered medically necessary to inhibit wound healing to prevent the conjunctiva scarring down on to the sclera.

Page 3 of 14 Currently available FDA-approved implants include: Ahmed glaucoma implant, Baerveldt seton, Ex-PRESS mini glaucoma shunt, Glaucoma pressure regulator, Krupin-Denver valve implant, Molteno implant, Schocket shunt
* First line examples include latanoprost or timolol; second line, brimonidine or dorzolamide, etc.

B. Insertion of the Hydrus® Microstent, iStent® Trabecular Micro-Bypass Stent system, or the iStent inject® Trabecular Micro-Bypass System is considered medically necessary when used in combination with cataract surgery for mild to moderate open-angle glaucoma, and a cataract, in adult members being treated with ocular hypotensive medication. C. Insertion of the XEN Glaucoma Treatment System (aka XEN45) device is covered for the management of refractory glaucoma, defined as prior failure of filtering/cilioablative procedure and/or uncontrolled IOP (progressive damage and mean diurnal medicated IOP ≥20 mm Hg) on maximally tolerated medical therapy (i.e., ≥4 classes of topical IOP-lowering medications, or fewer in the case of tolerability or efficacy issues). The insertion must be performed by an ophthalmologist with experience with trabeculectomy and bleb management. D. Insertion of the iStent infinite® Trabecular Micro-Bypass System Model iS3 considered medically necessary for use in adult patients with primary open-angle glaucoma in whom previous medical and surgical treatment has failed E. Adjunctive use of anti-fibrotic agents (e.g., mitomycin C) is considered medically necessary for use Ex-PRESS® Glaucoma Filtration Device (previously the Ex-PRESS™ with the mini glaucoma shunt) Limitations/Exclusions The following treatments/procedures are not considered medically necessary due to insufficient evidence of therapeutic value:

Transciliary filtration for glaucoma or other indications (e.g., Fugo Blade transciliary filtration, Singh filtration)
Ab interno trabeculectomy (trabectome) (CPT 0621T, 0622T)
Motorized ab interno trephination of sclera (sclerostomy), or trabecular meshwork (trabeculostomy), 1 or more, including injection of antifibrotic agents (CPT 1012T eff. 1/1/2026)
Beta radiation
Glaucoma drainage devices without FDA approval (e.g., Eyepass™ Glaucoma Implant, DeepLight® Glaucoma Treatment System , which are inserted internally)
Adjunctive use of anti-fibrotic agents (e.g., mitomycin C) or systemic corticosteroids with shunt implants other than the Ex-Press
Drug-eluting implants inserted into the lacrimal canaliculus (including punctal dilation and implant removal when performed) for glaucoma or ocular hypertension (CPT 0356T, 0444T and 0445T)
Requests for trabeculoplasty for ocular hypertension will be reviewed on a case-by-case basis for members who have failed pharmaceutical management

Page 4 of 14 Procedure Codes
0449T Insertion of aqueous drainage device, without extraocular reservoir, internal approach, into the subconjunctival space; initial device 0450T Insertion of aqueous drainage device, without extraocular reservoir, internal approach, into the subconjunctival space; each additional device (List separately in addition to code for primary procedure) 0671T Insertion of anterior segment aqueous drainage device into the trabecular meshwork, without external reservoir, and without concomitant cataract removal, one or more
65855 Trabeculoplasty by laser surgery 66150 Fistulization of sclera for glaucoma; trephination with iridectomy 66155 Fistulization of sclera for glaucoma; thermocauterization with iridectomy 66160 Fistulization of sclera for glaucoma; sclerectomy with punch or scissors, with iridectomy 66180 Aqueous shunt to extraocular equatorial plate reservoir, external approach; with graft 66183 Insertion of anterior segment aqueous drainage device, without extraocular reservoir, external approach 66184 Revision of aqueous shunt to extraocular equatorial plate reservoir; without graft 66185 Revision of aqueous shunt to extraocular equatorial plate reservoir; with graft 66710 Ciliary body destruction; cyclophotocoagulation, transscleral 66720 Ciliary body destruction; cryotherapy 66761 Iridotomy/iridectomy by laser surgery (eg, for glaucoma) (per session) 66989 Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; with insertion of intraocular (eg, trabecular meshwork, supraciliary, suprachoroidal) anterior segment aqueous drainage device, without extraocular reservoir, internal approach, one or more 66991 Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); with insertion of intraocular (eg, trabecular meshwork, supraciliary, suprachoroidal) anterior segment aqueous drainage device, without extraocular reservoir, internal approach, one or more
J0171 Injection, Adrenalin, epinephrine, 0.1 mg J1120 Injection, acetazolamide sodium, up to 500 mg J7315 Mitomycin, opthalmic, 0.2 mg L8612 Aqueous shunt

ICD-10 Diagnoses H25.10 Age-related nuclear cataract, unspecified eye
H25.11 Age-related nuclear cataract, right eye
H25.12 Age-related nuclear cataract, left eye
H25.13 Age-related nuclear cataract, bilateral

Page 5 of 14 H25.20 Age-related cataract, morgagnian type, unspecified eye
H25.21 Age-related cataract, morgagnian type, right eye
H25.22 Age-related cataract, morgagnian type, left eye
H25.23 Age-related cataract, morgagnian type, bilateral
H25.811 Combined forms of age-related cataract, right eye
H25.812 Combined forms of age-related cataract, left eye
H25.813 Combined forms of age-related cataract, bilateral
H25.819 Combined forms of age-related cataract, unspecified eye
H25.89 Other age-related cataract
H25.9 Unspecified age-related cataract
H26.001 Unspecified infantile and juvenile cataract, right eye
H26.002 Unspecified infantile and juvenile cataract, left eye
H26.003 Unspecified infantile and juvenile cataract, bilateral
H26.009 Unspecified infantile and juvenile cataract, unspecified eye
H26.011 Infantile and juvenile cortical, lamellar, or zonular cataract, right eye
H26.012 Infantile and juvenile cortical, lamellar, or zonular cataract, left eye
H26.013 Infantile and juvenile cortical, lamellar, or zonular cataract, bilateral
H26.019 Infantile and juvenile cortical, lamellar, or zonular cataract, unspecified eye
H26.031 Infantile and juvenile nuclear cataract, right eye
H26.032 Infantile and juvenile nuclear cataract, left eye
H26.033 Infantile and juvenile nuclear cataract, bilateral
H26.039 Infantile and juvenile nuclear cataract, unspecified eye
H26.041 Anterior subcapsular polar infantile and juvenile cataract, right eye
H26.042 Anterior subcapsular polar infantile and juvenile cataract, left eye
H26.043 Anterior subcapsular polar infantile and juvenile cataract, bilateral
H26.049 Anterior subcapsular polar infantile and juvenile cataract, unspecified eye
H26.051 Posterior subcapsular polar infantile and juvenile cataract, right eye
H26.052 Posterior subcapsular polar infantile and juvenile cataract, left eye
H26.053 Posterior subcapsular polar infantile and juvenile cataract, bilateral
H26.059 Posterior subcapsular polar infantile and juvenile cataract, unspecified eye
H26.061 Combined forms of infantile and juvenile cataract, right eye
H26.062 Combined forms of infantile and juvenile cataract, left eye
H26.063 Combined forms of infantile and juvenile cataract, bilateral
H26.069 Combined forms of infantile and juvenile cataract, unspecified eye
H26.09 Other infantile and juvenile cataract

Page 6 of 14 H26.101 Unspecified traumatic cataract, right eye
H26.102 Unspecified traumatic cataract, left eye
H26.103 Unspecified traumatic cataract, bilateral
H26.109 Unspecified traumatic cataract, unspecified eye
H26.111 Localized traumatic opacities, right eye
H26.112 Localized traumatic opacities, left eye
H26.113 Localized traumatic opacities, bilateral
H26.119 Localized traumatic opacities, unspecified eye
H26.121 Partially resolved traumatic cataract, right eye
H26.122 Partially resolved traumatic cataract, left eye
H26.123 Partially resolved traumatic cataract, bilateral
H26.129 Partially resolved traumatic cataract, unspecified eye
H26.131 Total traumatic cataract, right eye
H26.132 Total traumatic cataract, left eye
H26.133 Total traumatic cataract, bilateral
H26.139 Total traumatic cataract, unspecified eye
H26.20 Unspecified complicated cataract
H26.211 Cataract with neovascularization, right eye
H26.212 Cataract with neovascularization, left eye
H26.213 Cataract with neovascularization, bilateral
H26.219 Cataract with neovascularization, unspecified eye
H26.221 Cataract secondary to ocular disorders (degenerative) (inflammatory), right eye
H26.222 Cataract secondary to ocular disorders (degenerative) (inflammatory), left eye
H26.223 Cataract secondary to ocular disorders (degenerative) (inflammatory), bilateral
H26.229 Cataract secondary to ocular disorders (degenerative) (inflammatory), unspecified eye
H26.231 Glaucomatous flecks (subcapsular), right eye
H26.232 Glaucomatous flecks (subcapsular), left eye
H26.233 Glaucomatous flecks (subcapsular), bilateral
H26.239 Glaucomatous flecks (subcapsular), unspecified eye
H26.30 Drug-induced cataract, unspecified eye
H26.31 Drug-induced cataract, right eye
H26.32 Drug-induced cataract, left eye
H26.33 Drug-induced cataract, bilateral
H26.40 Unspecified secondary cataract
H26.411 Soemmering's ring, right eye

Page 7 of 14 H26.412 Soemmering's ring, left eye
H26.413 Soemmering's ring, bilateral
H26.419 Soemmering's ring, unspecified eye
H26.491 Other secondary cataract, right eye
H26.492 Other secondary cataract, left eye
H26.493 Other secondary cataract, bilateral
H26.499 Other secondary cataract, unspecified eye
H26.8 Other specified cataract
H26.9 Unspecified cataract
H40.012 Open angle with borderline findings, low risk, left eye H40.013 Open angle with borderline findings, low risk, bilateral H40.019 Open angle with borderline findings, low risk, unspecified eye H40.021 Open angle with borderline findings, high risk, right eye H40.022 Open angle with borderline findings, high risk, left eye H40.023 Open angle with borderline findings, high risk, bilateral H40.029 Open angle with borderline findings, high risk, unspecified eye H40.031 Anatomical narrow angle, right eye H40.032 Anatomical narrow angle, left eye H40.033 Anatomical narrow angle, bilateral H40.051 Ocular hypertension, right eye H40.052 Ocular hypertension, left eye H40.053 Ocular hypertension, bilateral H40.059 Ocular hypertension, unspecified eye H40.10X1 Unspecified open-angle glaucoma, mild stage
H40.10X2 Unspecified open-angle glaucoma, moderate stage
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 H40.1121 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 H40.1131 Primary open-angle glaucoma, bilateral, mild stage
H40.1132 Primary open-angle glaucoma, bilateral, moderate stage

Page 8 of 14 H40.1133 Primary open-angle glaucoma, bilateral, severe stage H40.1134 Primary open-angle glaucoma, bilateral, indeterminate stage H40.1191 Primary open-angle glaucoma, unspecified eye, mild stage
H40.1192 Primary open-angle glaucoma, unspecified eye, moderate stage
H40.1211 Low-tension glaucoma, right eye, mild stage H40.1212 Low-tension glaucoma, right eye, moderate stage H40.1213 Low-tension glaucoma, right eye, severe stage H40.1214 Low-tension glaucoma, right eye, indeterminate stage H40.1221 Low-tension glaucoma, left eye, mild stage H40.1222 Low-tension glaucoma, left eye, moderate stage H40.1223 Low-tension glaucoma, right eye, severe stage H40.1224 Low-tension glaucoma, left eye, indeterminate stage H40.1231 Low-tension glaucoma, bilateral, mild stage H40.1232 Low-tension glaucoma, bilateral, moderate stage H40.1233 Low-tension glaucoma, bilateral, severe stage H40.1234 Low-tension glaucoma, bilateral, indeterminate stage H40.1311 Pigmentary glaucoma, right eye, mild stage H40.1312 Pigmentary glaucoma, right eye, moderate stage H40.1313 Pigmentary glaucoma, right eye, severe stage H40.1314 Pigmentary glaucoma, right eye, indeterminate stage H40.1321 Pigmentary glaucoma, left eye, mild stage H40.1322 Pigmentary glaucoma, left eye, moderate stage H40.1323 Pigmentary glaucoma, left eye, severe stage H40.1324 Pigmentary glaucoma, left eye, indeterminate stage H40.1331 Pigmentary glaucoma, left eye, mild stage H40.1332 Pigmentary glaucoma, bilateral, moderate stage H40.1333 Pigmentary glaucoma, bilateral, severe stage H40.1334 Pigmentary glaucoma, bilateral, indeterminate stage H40.1411 Capsular glaucoma with pseudoexfoliation of lens, right eye, mild stage H40.1412 Capsular glaucoma with pseudoexfoliation of lens, right eye, moderate stage H40.1413 Capsular glaucoma with pseudoexfoliation of lens, right eye, severe stage H40.1414 Capsular glaucoma with pseudoexfoliation of lens, right eye, indeterminate stage H40.1421 Capsular glaucoma with pseudoexfoliation of lens, left eye, mild stage H40.1422 Capsular glaucoma with pseudoexfoliation of lens, left eye, moderate stage H40.1423 Capsular glaucoma with pseudoexfoliation of lens, left eye, severe stage

Page 9 of 14 H40.1424 Capsular glaucoma with pseudoexfoliation of lens, left eye, indeterminate stage H40.1431 Capsular glaucoma with pseudoexfoliation of lens, bilateral, moderate stage H40.1432 Capsular glaucoma with pseudoexfoliation of lens, bilateral, moderate stage H40.1433 Capsular glaucoma with pseudoexfoliation of lens, bilateral, severe stage H40.1434 Capsular glaucoma with pseudoexfoliation of lens, bilateral, indeterminate stage H40.89 Other specified glaucoma Q12.0 Congenital cataract

Specialty matched clinical peer review.

Revision History Company(ies) DATE REVISION EmblemHealth Nov. 14, 2025 Updated device branding Added CPT 0450T as covered
Added CPT 1012T as investigational
EmblemHealth Mar. 14, 2025 Transferred policy content to individual company branded template EmblemHealth Apr. 14, 2023
Added iStent infinite® indication

Page 14 of 14 ConnectiCare EmblemHealth ConnectiCare Sept. 11, 2020 Added a note pertaining to trabeculectomy regarding the prophylactic use of 5‐ Fluorouracil (5‐FU)
EmblemHealth ConnectiCare Jul. 8, 2020 Added case-by-case review language for trabeculoplasty as a treatment for ocular hypertension EmblemHealth ConnectiCare Jan. 10, 2020 Added iStent inject coverage and case-by-case language for goniotomy EmblemHealth ConnectiCare Dec. 14, 2018 Added coverage for Hydrus EmblemHealth ConnectiCare Sept. 14, 2018 Removed CyPass as a covered device due to Alcon recall Aug. 8, 2018 EmblemHealth ConnectiCare Mar. 9, 2018 Added coverage for CyPass and XEN45 devices

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