These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan will be used to determine your coverage.
Prior authorization is not required for iStent® (0191T) or ExPress® shunt (66183).
The minimally invasive glaucoma surgery devices (MIGS), iStent® and ExPress® shunt, are generally covered subject to the indications listed below and per your plan documents.
Indications that are covered
ExPress shunt (66183) is covered for treatment of of refractory primary open-angle glaucoma when first and second line drugs have failed to control intra-ocular pressure.
iStent® is covered for treatment of mild or moderate open-angle glaucoma and combined with cataract surgery in patients currently being treated with ocular hypotensive medication.
Glaucoma refers to a group of eye conditions that lead to damage to the optic nerve. This nerve carries visual information from the eye to the brain. In most cases, damage to the optic nerve is due to increased pressure in the eye, also known as intraocular pressure (IOP).
Minimally invasive glaucoma surgery (MIGS) refers to a variety of new techniques that expand the options of glaucoma treatment. Their main advantage is that they are non-penetrating, which means they are less invasive and safer than standard surgical treatment. Because they do not produce as large a pressure lowering effect, they are usually reserved for patients with less advanced disease or in combination with cataract surgery.
The MIGS addressed in this policy are:
ExPress® shunt (66183) - stainless steel mini-shunt drains aqueous fluid into the subconjunctival space and is used in conjunction with standard trabeculectomy surgery. It is placed under the scleral flap and into the anterior chamber so no sclerectomy or iridectomy is required. This makes the surgery safer and provides some resistance to flow.
iStent® (0191T) – a small titanium stent that drains aqueous fluid into Schlemm’s canal. It is used to treat early to moderate glaucoma and can be combined with cataract surgery.
If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.
Do not require prior authorization, covered:
|66183||Insertion of anterior segment aqueous drainage device, without extraocular reservoir, external approach|
|0191T||Insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the trabecular meshwork; initial insertion|
|0253T||Insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the suprachoroidal space|
|0376T||Insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the trabecular meshwork; each additional device insertion (List separately in addition to code for primary procedure)|
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- Hayes TB. “ExPRESS glaucoma filtration device (Alcon Inc) for treatment of primary open-angle glaucoma.” Sept 23, 2011
- Hayes TB Update. “ExPRESS glaucoma filtration device (Alcon Inc) for treatment of primary open-angle glaucoma.” Sept 26, 2012
- ECRI Emerging Technology Evidence Report. “Trabecular Micro-bypass Stent (iStent) for treating open-angle glaucoma.” 3/11/13
- Hayes Technology Brief. “iStent Trabecular Micro-Bypass Stent (Glaukos Corp.) for Treatment of Primary Open-Angle Glaucoma” 3/2/13.
This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.