Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for Ex-Press Glaucoma Filtration Device, Hydrus Microstent, or iStent Trabecular or Inject Trabecular Micro-Bypass Stent. The health plan has denied this test as experimental/investigational. According to the medical record, the patient was diagnosed with glaucoma, cataracts, macular degeneration, bilateral retinal hemorrhage, ocular hypertension, hypertension, atrial fibrillation, and diabetes mellitus.  He has been using eye drops including BromSite, Durezol, and Combigan for intraocular pressure.  The clinical note indicates the patient presented for cataract evaluation to the right eye.  The patient stated that the vision in the right eye had been getting worse for six months at all distances with a lot of glare at night and with bright sun.  Both eyes were dry.  The patient was utilizing artificial tears on occasion, which helped.  There was no pain in the bilateral eyes but some redness. The patient had a visual acuity in the right eye of 20/100+ and the left eye of 20/250.  With correction, the right eye was 20/100+ in the left eye was 20/150.  The visual field had constriction superior to the bilateral eyes.  Intraocular pressure was 20 to the bilateral eyes.  The provider states that the Combigen failed and the patient had trouble performing activities of daily living secondary to cataracts and the patient would like to undergo surgical intervention to improve quality of life. Medical literature indicates that minimally invasive glaucoma surgery aims to provide a medication-sparing, conjunctival-sparing, approach from inside the eye method to intraocular pressure reduction for patients with mild-to-moderate glaucoma that is safer than traditional incisional glaucoma surgery. The treatment has similar effectiveness but has been shown to be safer since these procedures are less invasive and spare the conjunctiva. These are less invasive procedures over the traditional glaucoma surgery for mild to moderate glaucoma.  Literature also indicates that the iStent has the ability to lower intraocular pressure significantly after short term follow up with a favorable risk profile.  This procedure is considered to be a micro-invasive glaucoma procedure, and is considered safer. The iStent would potentially enable the reduction or discontinuation of glaucoma drops.  The expected decrease in intraocular pressure is similar to the effect of a single pressure lower topical agent.  The treatment has been shown to be safer and less invasive than normal glaucoma surgery for the patients diagnosis.  Final Result: Two of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Therefore, the health plans denial is overturned.Credentials/Qualifications: Three reviewers are board certified in Ophthalmology and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.