Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Glaucoma. 
Treatment: Current Procedural Terminology (CPT) code 66174, transluminal dilation of aqueous outflow canal; without retention of device or stent. 

The insurer denied coverage for CPT code 66174, transluminal dilation of aqueous outflow canal; without retention of device or stent. 

The denial is overturned. 

This is a patient with a history of glaucoma and diabetes who presented to the ophthalmologist's office for evaluation of his glaucoma. The patient tried and failed conservative measures to treat glaucoma. He had laser therapy a few years ago. 

The patient underwent cataract extraction and transluminal dilation of the aqueous outflow canal. 

The ophthalmologist stated that patient has permanent blindness due to bilateral glaucoma-severe stage.  It was noted that patient has tried and failed standard treatment for glaucoma, including topical medications and laser procedure, and that viscocanaloplasty is likely to be more beneficial than any standard treatment for the patient's disease.  The patient is currently on three medications (Latanoprost, Alphagan P, and Dorzolamide) with inadequate control of intraocular pressures.  The patient received laser treatment for glaucoma but did not control intraocular pressure to acceptable level. 

The peer-reviewed literature does support a result of improvement in health outcome with viscocanalostomy.  Viscocanalostomy has been shown to lower intraocular pressure in patients have failed medical glaucoma therapy. 

CPT 66174 has the final approval from the appropriate regulatory body for the treatment for open-angle glaucoma. 

The patient is a good candidate for CPT 66174.  The patient has tried and failed standard medical and laser therapy for glaucoma, with his intraocular pressure not being adequately controlled with these treatments.  Thus, CPT 66174 is a good alternative for treating his glaucoma and controlling intraocular pressures. 

CPT 66174 is the best available treatment for this patient at this time.  Small randomized controlled trials comparing visocanalostomy with trabeculectomy shows that trabeculectomy has a greater intraocular pressure lowering effect than visocanalostomy, but with higher post-operative complications (1).  Visocanalostomy has been shown to be effective in lower intraocular pressure and sustaining this reduction over time (4).  Thus, CPT 66174 offers the best available treatment for this patient, while minimizing the potential complications associated with alternative surgical glaucoma procedures. 

The adverse risks are not increased over standard treatment/services.  The complications seen in filtering surgery (i.e., trabeculectomy) are largely eliminated by viscocanaloplasty.  There is no post-operative bleb management needed, and hypotony-related compilations are largely avoided with viscocanaloplasty compared to standard trabeculectomy surgery (2). 

CPT 66174 is likely to be more beneficial than any of the standard procedures/treatments for this patient. The patient has glaucoma that has been uncontrolled with standard medical and laser treatment.  Viscocanaloplasty is more beneficial for this patient's condition, as it can help control intraocular pressure while minimizing the potential complications associated with standard filtering glaucoma surgery. 

The carrier's denial of current procedural terminology (CPT) code 66174, transluminal dilation of aqueous outflow canal; without retention of device or stent should be overturned.