Humana Commercial Clinical Policy

Humana Glaucoma Surgical Treatments Form



Trabeculectomy

Indications

(262132) Is the patient's treatment related to glaucoma? 

Trabeculoplasty

Indications

(262133) Is the patient's treatment related to glaucoma? 

Iridotomy

Indications

(262134) Is the patient's treatment related to glaucoma? 

Iridectomy

Indications

(262135) Is the patient's treatment related to glaucoma? 

Iridoplasty

Indications

(262136) Is the patient's treatment related to glaucoma? 

Ahmed Glaucoma Valve Placement or Revision

Indications

(262137) Is the procedure an initial placement or revision of the Ahmed glaucoma valve? 

Baerveldt Glaucoma Implant Placement or Revision

Indications

(262138) Is the procedure an initial placement or revision of the Baerveldt glaucoma implant? 

Krupin Eye Valve Placement or Revision

Indications

(262139) Is the procedure an initial placement or revision of the Krupin eye valve? 

Molteno Implant Placement or Revision

Indications

(262140) Is the procedure an initial placement or revision of the Molteno implant? 

Canaloplasty

Notes: CPT codes 66174 and 66175 related to canaloplasty are specifically excluded from coverage as they are considered experimental/investigational.

Indications

(262141) Is the proposed use of canaloplasty for treatment documented and widely acknowledged as effective in nationally recognized peer-reviewed medical literature published in the English language? 

Contraindications

(262142) Is the canaloplasty requested for an experimental or investigational purpose? 
Effective Date

04/27/2023

Last Reviewed

NA

Original Document

  Reference



Glaucoma Surgical Treatments

Medical Coverage Policy

Effective Date:

04/27/2023

Revision Date:

04/27/2023

Review Date:

04/27/2023

Policy Number:

HUM-0475-029

Change Summary:

Updated Description, Coverage Determination, Coverage Limitations, Medical Alternatives, References

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Disclaimer

Medical Alternatives

Description