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Glaucoma Surgery (CPB 0484, reviewed 2026-07-14)

Aetna·Ophthalmology·Surgery
Effective date
Jul 14, 2026
We identified it
Aug 15, 2026
Days to comply

Summary

Aetna has updated its Glaucoma Surgery clinical policy (CPB 0484, effective 2026-07-14) clarifying coverage for multiple surgical techniques including laser trabeculoplasty, FDA-approved shunt implants, micro-bypass stents (iStent, Hydrus), XEN system, and goniotomy/trabeculotomy procedures. The policy establishes specific medical necessity criteria, contraindications, and experimental/investigational determinations that will affect billing, prior authorization requirements, and claim adjudication for glaucoma surgeries.

Action Required

Action needed
By 2026-07-14, billing team must: (1) Update billing system rules to reflect covered procedures (laser trabeculoplasty CPT 65855, shunt implants CPT 0449T/0450T/66180/66183, iStent with cataract CPT 66989/66991, Hydrus with cataract, XEN system, goniotomy CPT 65820 with specified devices, ab interno canaloplasty); (2) Configure prior authorization triggers for CPT 0449T, 0450T, 65820 requiring documentation that first/second-line medications have failed and IOP control criteria are met; (3) Block as non-covered (experimental): CPT 0253T, 0474T, 0671T, iStent G3 Supra, excimer laser trabeculostomy (0253T), FLIGHT trabeculotomy, MINT, more than 2 iStents per eye, more than 1 Hydrus per eye, standalone iStent Infinite, cataract combined with ab interno canaloplasty and micro-bypass stents, and AI-based glaucoma applications; (4) Flag contraindications in system: iStent contraindicated for angle-closure glaucoma, neovascular glaucoma, Sturge-Weber, elevated episcleral venous pressure; Hydrus contraindicated for anterior chamber angle defects, angle-closure, neovascular glaucoma, malignant glaucoma, traumatic glaucoma, uveitic glaucoma; (5) Update medical necessity templates to capture: ocular hypertension IOP levels, medication trial documentation, member compliance barriers (manual dexterity, dementia, caregiver unavailability), contralateral eye surgical history; (6) Add restriction that mitomycin C (J7315) is only covered adjunctively with Ex-PRESS shunt (CPT 0253T), not with other shunts; (7) Educate providers on CPT 65820 (goniotomy) coding rules—cannot be billed with other angle surgeries, stent insertions, or Schlemm canal implants, and requires 3+ clock hours TM incision; multiple goniopunctures do not meet CPT description. Claims submitted without meeting medical necessity criteria, contraindication checks, or required prior authorization will be denied.

Affected Billing Codes

65820
65855
66150
66155
66160
66180
66183
66185
66710
66720
66761
66989
66991
J7315
J9190