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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that glaucoma surgical aqueous drainage devices will be considered medically reasonable and 
necessary when approved by the Food and Drug Administration (FDA) and used within accordance of the 
FDA-approved/cleared indications. 
 
1.  A single insertion per eye of an anterior segment aqueous drainage device(s), without extraocular reservoir, 
via internal approach into the trabecular meshwork or with creation of intraocular reservoir into the supraciliary 
space is considered medically reasonable and necessary in conjunction with cataract surgery for the treatment 
of adults with mild or moderate open-angle glaucoma and a cataract when the individual is currently being 
treated with an ocular hypotensive medication. 
 
2. A single insertion per eye of an aqueous drainage device(s) without extraocular reservoir, via internal 
approach into the subconjunctival space is considered medically reasonable and necessary as a standalone 
treatment for refractory glaucoma, defined as prior failure of filtering/cilioablative procedure and/or 
uncontrolled intraocular pressure (IOP) on maximally tolerated medical therapy. 
 
Limitations 
 
The following are considered not medically reasonable and necessary: 
1. Glaucoma drainage devices that do not have FDA approval/clearance and/or devices that have been recalled. 
2. Glaucoma drainage devices used outside of the FDA approval/clearance. 
3. Insertion of an anterior segment aqueous drainage device without extraocular reservoir, via internal approach 
into the suprachoroidal space. 
4. Additional insertions of anterior segment aqueous drainage device(s) without extraocular reservoir, via 
internal approach into the trabecular meshwork. 
5. Additional insertions of aqueous drainage device(s) without extraocular reservoir, via internal approach into 
the subconjunctivial space. 
6. A single insertion of an FDA-approved/cleared anterior segment aqueous drainage device(s) without 
extraocular reservoir, via internal approach into the trabecular meshwork or with creation of intraocular 
reservoir via internal approach into the supraciliary space not performed in conjunction with cataract surgery. 7. Goniotomy procedure performed in conjunction with the insertion of a glaucoma drainage device. Routine 
performance of goniotomy with insertion of a glaucoma drainage device may be subject to focused medical 
review. 
8. Trabeculectomy procedure performed in conjunction with the insertion of a glaucoma drainage device. 
Routine performance may be subject to focused medical review. 
9. Insertion of glaucoma drainage device(s) into the trabecular meshwork or into the supraciliary space are 
limited to one insertor per eye when performed in conjunction with cataract surgery and when the medically 
reasonable and necessary criteria as stated above are met. 
- Additional insertor use for device insertions on one eye is considered not medically reasonable and necessary. 
10. Insertion of glaucoma drainage device(s) into the subconjunctival space are limited to one insertion per eye 
per day when the medically reasonable and necessary criteria as stated above are met. 
- Additional device insertions are considered not medically reasonable and necessary. 
 
You can find this information in the Local Coverage Determination (LCD): Micro-Invasive Glaucoma Surgery 
(MIGS) (L38223). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.