Advocacy Works: Cigna’s Glaucoma Surgery Coverage Policy

The Problem

When insurer Cigna’s coverage policy on glaucoma surgical procedures restricted access to sight-saving treatment, the Academy spearheaded a campaign to reverse it. Cigna was considering goniotomy, gonioscopy-assisted transluminal trabeculotomy and canaloplasty in combination with trabeculotomy ab interno to be experimental, investigational or unproven for any indication.

Academy and Its Partners Responded

On Feb. 6, the Academy and American Society of Cataract and Refractive Surgery (ASCRS) sent a joint letter urging Cigna to reverse its noncoverage determinations for the treatments. We provided extensive literature illustrating the history of effective use of these procedures in adults to support medical necessity.

Results

Effective June 15, Cigna reversed its policy not to cover adult goniotomy and canaloplasty procedures. The policy (PDF) now says that canaloplasty (CPT Code 66174, 66175) is covered, whether performed ab externo or ab interno, and is considered medically necessary in an individual 18 years or older for the treatment of open-angle glaucoma when there is failure, intolerance or contraindication to conventional medical management (i.e., topical or oral medication).

Goniotomy (i.e., trabeculotomy, trabeculotomy ab interno) (CPT Code 65820) is considered medically necessary for the reduction of intraocular pressure in an individual with glaucoma when performed using a Food and Drug Administration-approved device.

“The Academy strongly believes it is critical for patients and their treating ophthalmologist to have access to all approved medical, laser and surgical interventions and that it should be at the discretion of the treating ophthalmologist to select the intervention that they deem most likely to successfully lower the patient’s eye pressure, stabilize their disease and prevent vision loss,” said Michael X. Repka, MD, the Academy’s medical director for Governmental Affairs.