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Decision: unknown

 
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 say 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 r
 reservoir, via internal approach into the trabecular meshwork or with creation of intraocular reservoir I
 into the supraciliary space is considered medically reasonable and necessary in conjunction with c
 cataract surgery for the treatment of adults with mild or moderate open-angle glaucoma and a cataract w
 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 s
 standalone treatment for refractory glaucoma, defined as prior failure of filtering/cilioablative procedure 
 and/or uncontrolled intraocular pressure (IOP) (progressive damage and/or mean diurnal medicated IOP 
 greater than or equal to 20 mmHg) on maximally tolerated medical therapy (i.e., greater than or equal to  
4 classes of topical IOP-lowering medications, or fewer in the case of tolerability or efficacy issues). 
The following are considered not medically reasonable and necessary: 
 
- Glaucoma drainage devices that do not have FDA approval/clearance and/or devices that have been 
recalled. 
- Glaucoma drainage devices used outside of the FDA approval/clearance. 
- Insertion of an anterior segment aqueous drainage device without extraocular reservoir, via internal 
approach into the suprachoroidal space. 
- Additional insertions of anterior segment aqueous drainage device(s) without extraocular reservoir, via 
internal approach into the trabecular meshwork. 
- Additional insertions of aqueous drainage device(s) without extraocular reservoir, via internal 
approach into the subconjunctivial space. 
- 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. 
- 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. 
- Trabeculectomy procedure performed in conjunction with the insertion of a glaucoma drainage device. 
- Routine performance may be subject to focused medical review. 
- Insertion of glaucoma drainage device(s) (i.e. one or two microstents) 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. 
- 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.