This version of the policy will become effective 10/22/2018.
Medical necessity criteria have been revised regarding the covered approaches used for aqueous shunts and stents. Ab interno aqueous stents are considered investigational.
Text added to clarify billing requirements for microstents
The following CPT codes have been added to this policy:
66180 and 66185
When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
Policy: 00.10.17h:Modifier 66: Surgical Team
Policy: 00.10.18j:Modifiers for Assistant-at-Surgery Services: 80, 81, 82, and AS
Policy: 03.00.05i:Modifier 50: Bilateral Procedure
Policy: 03.00.20i:Modifiers 26 (Professional Component) and TC (Technical Component)
Policy: 03.00.28l:Modifier 79: Unrelated Procedure or Service by the Same Physician During the Postoperative Period
Policy: 07.13.06k:Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
Policy: 07.13.07j:Corneal Pachymetry Using Ultrasound
Policy: 11.01.07d:Cataract Surgery
Policy: 12.01.01ar:Experimental/Investigational Services
Policy: 11.00.10u:Multiple Surgical Reduction Guidelines (Independence)
The following CPT codes have been added to this policy: 66180 and 66185