Aetna · Clinical coverage policy

Aetna Glaucoma Surgery coverage criteria

Aetna CPB 0484 covers glaucoma surgery as medically necessary in defined situations: laser trabeculoplasty and FDA-approved aqueous shunt implants for refractory primary open-angle glaucoma after both first- and second-line IOP drugs fail; iStent or Hydrus micro-bypass stents only in adults with mild/moderate open-angle glaucoma plus a cataract who are on an ocular hypotensive medication and only when done with cataract surgery; the XEN system for refractory/open-angle/pseudoexfoliative/pigmentary glaucoma unresponsive to maximum tolerated medical therapy; combined glaucoma-cataract surgery for visually significant cataract with glaucoma uncontrolled despite maximal therapy; and goniotomy/trabeculotomy. A long list of newer or unestablished devices and techniques (e.g., trabectome, GATT for juvenile-onset, CyPass, iStent G3 Supra/standalone iStent Infinite, >2 iStents or >1 Hydrus per eye, drug-eluting canalicular implants, suprachoroidal/non-FDA shunts, AI applications) is considered experimental/investigational, and the stents are contraindicated in angle-closure and certain secondary glaucomas. The bulletin is silent on precertification.

Policy CPB 0484 · Effective · Verify against the current Aetna policy before submitting — view source policy.

Payer

Aetna

Policy

CPB 0484

Prior auth

Confirm

Effective

January 1, 2026

This page reflects the coverage criteria captured from Aetna policy CPB 0484 and may not include every criterion, exception, or code — verify the complete bulletin before submitting.

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

When does Aetna cover Glaucoma Surgery (CPT 65820), and what gets it denied?

Path
Aetna CPB 0484 covers glaucoma surgery as medically necessary in defined situations: laser trabeculoplasty and FDA-approved aqueous shunt implants for refractory primary open-angle glaucoma after both first- and second-line IOP drugs fail; iStent or Hydrus micro-bypass stents only in adults with mild/moderate open-angle glaucoma plus a cataract who are on an ocular hypotensive medication and only when done with cataract surgery; the XEN system for refractory/open-angle/pseudoexfoliative/pigmentary glaucoma unresponsive to maximum tolerated medical therapy; combined glaucoma-cataract surgery for visually significant cataract with glaucoma uncontrolled despite maximal therapy; and goniotomy/trabeculotomy. A long list of newer or unestablished devices and techniques (e.g., trabectome, GATT for juvenile-onset, CyPass, iStent G3 Supra/standalone iStent Infinite, >2 iStents or >1 Hydrus per eye, drug-eluting canalicular implants, suprachoroidal/non-FDA shunts, AI applications) is considered experimental/investigational, and the stents are contraindicated in angle-closure and certain secondary glaucomas. The bulletin is silent on precertification. Coverage criteria include: Laser trabeculoplasty (medically necessary) for refractory primary open-angle glaucoma — requires that BOTH first-line drugs (e.g., latanoprost or timolol) AND second-line drugs (e.g., brimonidine or dorzolamide) have FAILED to control intra-ocular pressure (IOP).; FDA-approved aqueous drainage/shunt implants (medically necessary) for refractory primary open-angle glaucoma when first-line AND second-line drugs have failed to control IOP. Covered implants include (ONE of): Ahmed glaucoma implant OR Baerveldt seton OR Ex-PRESS mini glaucoma shunt OR glaucoma pressure regulator OR Krupin-Denver valve implant OR Molteno implant OR Schocket shunt.; iStent Trabecular Micro-Bypass Stents (medically necessary): one or two iStent stents per eye — requires ALL of: adult member; mild OR moderate open-angle glaucoma; a cataract; currently being treated with an ocular hypotensive medication; AND the procedure is performed in conjunction with cataract surgery.; Hydrus Microstent (medically necessary) — requires ALL of: adult member; mild OR moderate open-angle glaucoma; a cataract; currently being treated with an ocular hypotensive medication; AND the procedure is performed in conjunction with cataract surgery.; XEN Glaucoma Treatment System (medically necessary) for the management of refractory glaucoma — including (ONE of): cases where previous surgical treatment has failed; primary open-angle glaucoma; OR pseudoexfoliative or pigmentary glaucoma with open angles — that are unresponsive to maximum tolerated medical therapy.; Adjunctive use of anti-fibrotic agents (e.g., mitomycin C) (medically necessary) ONLY for use WITH the Ex-PRESS mini glaucoma shunt.; Combined glaucoma and cataract surgery (medically necessary) for persons with a visually significant cataract WITH uncontrolled glaucoma despite maximal medical therapy and/or laser trabeculoplasty.; Use of VisionGraft patch graft is considered integral in the treatment of glaucoma (i.e., covered as integral to the procedure).; Goniotomy or trabeculotomy (medically necessary) for treatment of glaucoma. (Definitions: Goniotomy = incision and/or excision of the trabecular meshwork (TM) to create an opening into Schlemm's canal via an internal approach through the anterior chamber; Trabeculotomy = an external approach using a deep scleral incision to access Schlemm's canal then rotating a probe into the anterior chamber to open the TM.). Applies to 7 codes: 65820, 65850, 65855, 66180, 66185, 66989, 66991.
Action
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source.
Trap
Policy exclusions and limitations: Experimental/investigational/unproven: Ab interno Kahook dual blade trabeculectomy for the treatment of primary congenital glaucoma.; Experimental/investigational/unproven: Ab interno trabeculectomy (trabectome) for the treatment of glaucoma.; Experimental/investigational/unproven: Artificial intelligence-based applications for the diagnosis, management, and progression detection of glaucoma.; Experimental/investigational/unproven: Beta radiation for the treatment of glaucoma.; Experimental/investigational/unproven: Cataract surgery combined with ab interno canaloplasty and micro-trabecular bypass stent surgery for the treatment of open-angle glaucoma.; Experimental/investigational/unproven: CyPass Micro-Stent, and the iStent G3 Supra.; Experimental/investigational/unproven: Excimer laser trabeculostomy for the treatment of glaucoma.; Experimental/investigational/unproven: Femtosecond laser image-guided high-precision trabeculotomy (FLIGHT) for the treatment of glaucoma.; Experimental/investigational/unproven: Gonioscopy-assisted transluminal trabeculotomy (GATT) for the treatment of juvenile-onset open-angle glaucoma.; Experimental/investigational/unproven: Implantation of a drug-eluting implant into lacrimal canaliculus during routine cataract removal.; Experimental/investigational/unproven: Insertion of a drug-eluting implant, including punctal dilation and implant removal when performed, into the lacrimal canaliculus for the treatment of glaucoma or ocular hypertension.; Experimental/investigational/unproven: Intra-operative optical coherence tomography in glaucoma surgery.; Experimental/investigational/unproven: Microcatheter-assisted trabeculotomy for the treatment of open-angle glaucoma.; Experimental/investigational/unproven: Minimally Invasive Nasal Trabeculostomy (MINT) (Sanoculis).; Experimental/investigational/unproven: More than 1 Hydrus Microstent per eye.; Experimental/investigational/unproven: More than 2 iStents per eye.; Experimental/investigational/unproven: Standalone iStent Infinite for the treatment of open-angle glaucoma.; Experimental/investigational/unproven: Sub-conjunctival injection of anti-vascular endothelial growth factor agent (e.g., bevacizumab, ranibizumab) for control of wound healing in glaucoma surgery.; Experimental/investigational/unproven: Suprachoroidal drainage of aqueous humor (suprachoroidal shunt), anterior segment aqueous drainage devices without extra-ocular reservoir inserted by an internal approach, and other shunts (e.g., the DeepLight Gold Micro-Shunt (SOLX), Eyepass Glaucoma Implant (GMP Companies, Inc.)) that have not been approved by the FDA for the treatment of glaucoma.; Experimental/investigational/unproven: Transciliary filtration (Fugo Blade transciliary filtration, Singh filtration) for the treatment of glaucoma or any other indications.; Experimental/investigational/unproven: Transorbital electrical stimulation for the treatment of open-angle glaucoma.; Experimental/investigational/unproven: Adjunctive use of anti-fibrotic agents (e.g., mitomycin C) or systemic corticosteroids with shunt implants OTHER THAN the Ex-PRESS mini glaucoma shunt.; Contraindication (non-coverage): iStent Trabecular Micro-Bypass Stent System is contraindicated for persons with primary angle-closure glaucoma, secondary angle-closure glaucoma (including neovascular glaucoma), retrobulbar tumor, thyroid eye disease, Sturge-Weber Syndrome, or any other type of condition that may cause elevated episcleral venous pressure.; Contraindication (non-coverage): Hydrus Microstent is contraindicated for persons with birth defects of the anterior chamber angle of the eye, primary angle-closure glaucoma, secondary angle-closure glaucoma (including neovascular glaucoma), malignant glaucoma, traumatic glaucoma, and uveitic glaucoma.; Coding restriction: Goniotomy should not be coded in addition to other angle surgeries, stent insertions, or Schlemm canal implants, or if the incision into the trabecular meshwork is minimal or simply incidental to another procedure. Claims may be denied when the requested service falls under these.

Source: Aetna CPB 0484 — Glaucoma Surgery

Coverage criteria

  • Laser trabeculoplasty (medically necessary) for refractory primary open-angle glaucoma — requires that BOTH first-line drugs (e.g., latanoprost or timolol) AND second-line drugs (e.g., brimonidine or dorzolamide) have FAILED to control intra-ocular pressure (IOP).
  • FDA-approved aqueous drainage/shunt implants (medically necessary) for refractory primary open-angle glaucoma when first-line AND second-line drugs have failed to control IOP. Covered implants include (ONE of): Ahmed glaucoma implant OR Baerveldt seton OR Ex-PRESS mini glaucoma shunt OR glaucoma pressure regulator OR Krupin-Denver valve implant OR Molteno implant OR Schocket shunt.
  • iStent Trabecular Micro-Bypass Stents (medically necessary): one or two iStent stents per eye — requires ALL of: adult member; mild OR moderate open-angle glaucoma; a cataract; currently being treated with an ocular hypotensive medication; AND the procedure is performed in conjunction with cataract surgery.
  • Hydrus Microstent (medically necessary) — requires ALL of: adult member; mild OR moderate open-angle glaucoma; a cataract; currently being treated with an ocular hypotensive medication; AND the procedure is performed in conjunction with cataract surgery.
  • XEN Glaucoma Treatment System (medically necessary) for the management of refractory glaucoma — including (ONE of): cases where previous surgical treatment has failed; primary open-angle glaucoma; OR pseudoexfoliative or pigmentary glaucoma with open angles — that are unresponsive to maximum tolerated medical therapy.
  • Adjunctive use of anti-fibrotic agents (e.g., mitomycin C) (medically necessary) ONLY for use WITH the Ex-PRESS mini glaucoma shunt.
  • Combined glaucoma and cataract surgery (medically necessary) for persons with a visually significant cataract WITH uncontrolled glaucoma despite maximal medical therapy and/or laser trabeculoplasty.
  • Use of VisionGraft patch graft is considered integral in the treatment of glaucoma (i.e., covered as integral to the procedure).
  • Goniotomy or trabeculotomy (medically necessary) for treatment of glaucoma. (Definitions: Goniotomy = incision and/or excision of the trabecular meshwork (TM) to create an opening into Schlemm's canal via an internal approach through the anterior chamber; Trabeculotomy = an external approach using a deep scleral incision to access Schlemm's canal then rotating a probe into the anterior chamber to open the TM.)

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

Frequently asked questions

When does Aetna cover Glaucoma Surgery (CPT 65820), and what gets it denied?
Aetna CPB 0484 covers glaucoma surgery as medically necessary in defined situations: laser trabeculoplasty and FDA-approved aqueous shunt implants for refractory primary open-angle glaucoma after both first- and second-line IOP drugs fail; iStent or Hydrus micro-bypass stents only in adults with mild/moderate open-angle glaucoma plus a cataract who are on an ocular hypotensive medication and only when done with cataract surgery; the XEN system for refractory/open-angle/pseudoexfoliative/pigmentary glaucoma unresponsive to maximum tolerated medical therapy; combined glaucoma-cataract surgery for visually significant cataract with glaucoma uncontrolled despite maximal therapy; and goniotomy/trabeculotomy. A long list of newer or unestablished devices and techniques (e.g., trabectome, GATT for juvenile-onset, CyPass, iStent G3 Supra/standalone iStent Infinite, >2 iStents or >1 Hydrus per eye, drug-eluting canalicular implants, suprachoroidal/non-FDA shunts, AI applications) is considered experimental/investigational, and the stents are contraindicated in angle-closure and certain secondary glaucomas. The bulletin is silent on precertification. Coverage criteria include: Laser trabeculoplasty (medically necessary) for refractory primary open-angle glaucoma — requires that BOTH first-line drugs (e.g., latanoprost or timolol) AND second-line drugs (e.g., brimonidine or dorzolamide) have FAILED to control intra-ocular pressure (IOP).; FDA-approved aqueous drainage/shunt implants (medically necessary) for refractory primary open-angle glaucoma when first-line AND second-line drugs have failed to control IOP. Covered implants include (ONE of): Ahmed glaucoma implant OR Baerveldt seton OR Ex-PRESS mini glaucoma shunt OR glaucoma pressure regulator OR Krupin-Denver valve implant OR Molteno implant OR Schocket shunt.; iStent Trabecular Micro-Bypass Stents (medically necessary): one or two iStent stents per eye — requires ALL of: adult member; mild OR moderate open-angle glaucoma; a cataract; currently being treated with an ocular hypotensive medication; AND the procedure is performed in conjunction with cataract surgery.; Hydrus Microstent (medically necessary) — requires ALL of: adult member; mild OR moderate open-angle glaucoma; a cataract; currently being treated with an ocular hypotensive medication; AND the procedure is performed in conjunction with cataract surgery.; XEN Glaucoma Treatment System (medically necessary) for the management of refractory glaucoma — including (ONE of): cases where previous surgical treatment has failed; primary open-angle glaucoma; OR pseudoexfoliative or pigmentary glaucoma with open angles — that are unresponsive to maximum tolerated medical therapy.; Adjunctive use of anti-fibrotic agents (e.g., mitomycin C) (medically necessary) ONLY for use WITH the Ex-PRESS mini glaucoma shunt.; Combined glaucoma and cataract surgery (medically necessary) for persons with a visually significant cataract WITH uncontrolled glaucoma despite maximal medical therapy and/or laser trabeculoplasty.; Use of VisionGraft patch graft is considered integral in the treatment of glaucoma (i.e., covered as integral to the procedure).; Goniotomy or trabeculotomy (medically necessary) for treatment of glaucoma. (Definitions: Goniotomy = incision and/or excision of the trabecular meshwork (TM) to create an opening into Schlemm's canal via an internal approach through the anterior chamber; Trabeculotomy = an external approach using a deep scleral incision to access Schlemm's canal then rotating a probe into the anterior chamber to open the TM.). Applies to 7 codes: 65820, 65850, 65855, 66180, 66185, 66989, 66991. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Policy exclusions and limitations: Experimental/investigational/unproven: Ab interno Kahook dual blade trabeculectomy for the treatment of primary congenital glaucoma.; Experimental/investigational/unproven: Ab interno trabeculectomy (trabectome) for the treatment of glaucoma.; Experimental/investigational/unproven: Artificial intelligence-based applications for the diagnosis, management, and progression detection of glaucoma.; Experimental/investigational/unproven: Beta radiation for the treatment of glaucoma.; Experimental/investigational/unproven: Cataract surgery combined with ab interno canaloplasty and micro-trabecular bypass stent surgery for the treatment of open-angle glaucoma.; Experimental/investigational/unproven: CyPass Micro-Stent, and the iStent G3 Supra.; Experimental/investigational/unproven: Excimer laser trabeculostomy for the treatment of glaucoma.; Experimental/investigational/unproven: Femtosecond laser image-guided high-precision trabeculotomy (FLIGHT) for the treatment of glaucoma.; Experimental/investigational/unproven: Gonioscopy-assisted transluminal trabeculotomy (GATT) for the treatment of juvenile-onset open-angle glaucoma.; Experimental/investigational/unproven: Implantation of a drug-eluting implant into lacrimal canaliculus during routine cataract removal.; Experimental/investigational/unproven: Insertion of a drug-eluting implant, including punctal dilation and implant removal when performed, into the lacrimal canaliculus for the treatment of glaucoma or ocular hypertension.; Experimental/investigational/unproven: Intra-operative optical coherence tomography in glaucoma surgery.; Experimental/investigational/unproven: Microcatheter-assisted trabeculotomy for the treatment of open-angle glaucoma.; Experimental/investigational/unproven: Minimally Invasive Nasal Trabeculostomy (MINT) (Sanoculis).; Experimental/investigational/unproven: More than 1 Hydrus Microstent per eye.; Experimental/investigational/unproven: More than 2 iStents per eye.; Experimental/investigational/unproven: Standalone iStent Infinite for the treatment of open-angle glaucoma.; Experimental/investigational/unproven: Sub-conjunctival injection of anti-vascular endothelial growth factor agent (e.g., bevacizumab, ranibizumab) for control of wound healing in glaucoma surgery.; Experimental/investigational/unproven: Suprachoroidal drainage of aqueous humor (suprachoroidal shunt), anterior segment aqueous drainage devices without extra-ocular reservoir inserted by an internal approach, and other shunts (e.g., the DeepLight Gold Micro-Shunt (SOLX), Eyepass Glaucoma Implant (GMP Companies, Inc.)) that have not been approved by the FDA for the treatment of glaucoma.; Experimental/investigational/unproven: Transciliary filtration (Fugo Blade transciliary filtration, Singh filtration) for the treatment of glaucoma or any other indications.; Experimental/investigational/unproven: Transorbital electrical stimulation for the treatment of open-angle glaucoma.; Experimental/investigational/unproven: Adjunctive use of anti-fibrotic agents (e.g., mitomycin C) or systemic corticosteroids with shunt implants OTHER THAN the Ex-PRESS mini glaucoma shunt.; Contraindication (non-coverage): iStent Trabecular Micro-Bypass Stent System is contraindicated for persons with primary angle-closure glaucoma, secondary angle-closure glaucoma (including neovascular glaucoma), retrobulbar tumor, thyroid eye disease, Sturge-Weber Syndrome, or any other type of condition that may cause elevated episcleral venous pressure.; Contraindication (non-coverage): Hydrus Microstent is contraindicated for persons with birth defects of the anterior chamber angle of the eye, primary angle-closure glaucoma, secondary angle-closure glaucoma (including neovascular glaucoma), malignant glaucoma, traumatic glaucoma, and uveitic glaucoma.; Coding restriction: Goniotomy should not be coded in addition to other angle surgeries, stent insertions, or Schlemm canal implants, or if the incision into the trabecular meshwork is minimal or simply incidental to another procedure. Claims may be denied when the requested service falls under these.
Does Aetna require prior authorization for Glaucoma Surgery?
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source.
What does Aetna exclude for Glaucoma Surgery?
Policy exclusions and limitations: Experimental/investigational/unproven: Ab interno Kahook dual blade trabeculectomy for the treatment of primary congenital glaucoma.; Experimental/investigational/unproven: Ab interno trabeculectomy (trabectome) for the treatment of glaucoma.; Experimental/investigational/unproven: Artificial intelligence-based applications for the diagnosis, management, and progression detection of glaucoma.; Experimental/investigational/unproven: Beta radiation for the treatment of glaucoma.; Experimental/investigational/unproven: Cataract surgery combined with ab interno canaloplasty and micro-trabecular bypass stent surgery for the treatment of open-angle glaucoma.; Experimental/investigational/unproven: CyPass Micro-Stent, and the iStent G3 Supra.; Experimental/investigational/unproven: Excimer laser trabeculostomy for the treatment of glaucoma.; Experimental/investigational/unproven: Femtosecond laser image-guided high-precision trabeculotomy (FLIGHT) for the treatment of glaucoma.; Experimental/investigational/unproven: Gonioscopy-assisted transluminal trabeculotomy (GATT) for the treatment of juvenile-onset open-angle glaucoma.; Experimental/investigational/unproven: Implantation of a drug-eluting implant into lacrimal canaliculus during routine cataract removal.; Experimental/investigational/unproven: Insertion of a drug-eluting implant, including punctal dilation and implant removal when performed, into the lacrimal canaliculus for the treatment of glaucoma or ocular hypertension.; Experimental/investigational/unproven: Intra-operative optical coherence tomography in glaucoma surgery.; Experimental/investigational/unproven: Microcatheter-assisted trabeculotomy for the treatment of open-angle glaucoma.; Experimental/investigational/unproven: Minimally Invasive Nasal Trabeculostomy (MINT) (Sanoculis).; Experimental/investigational/unproven: More than 1 Hydrus Microstent per eye.; Experimental/investigational/unproven: More than 2 iStents per eye.; Experimental/investigational/unproven: Standalone iStent Infinite for the treatment of open-angle glaucoma.; Experimental/investigational/unproven: Sub-conjunctival injection of anti-vascular endothelial growth factor agent (e.g., bevacizumab, ranibizumab) for control of wound healing in glaucoma surgery.; Experimental/investigational/unproven: Suprachoroidal drainage of aqueous humor (suprachoroidal shunt), anterior segment aqueous drainage devices without extra-ocular reservoir inserted by an internal approach, and other shunts (e.g., the DeepLight Gold Micro-Shunt (SOLX), Eyepass Glaucoma Implant (GMP Companies, Inc.)) that have not been approved by the FDA for the treatment of glaucoma.; Experimental/investigational/unproven: Transciliary filtration (Fugo Blade transciliary filtration, Singh filtration) for the treatment of glaucoma or any other indications.; Experimental/investigational/unproven: Transorbital electrical stimulation for the treatment of open-angle glaucoma.; Experimental/investigational/unproven: Adjunctive use of anti-fibrotic agents (e.g., mitomycin C) or systemic corticosteroids with shunt implants OTHER THAN the Ex-PRESS mini glaucoma shunt.; Contraindication (non-coverage): iStent Trabecular Micro-Bypass Stent System is contraindicated for persons with primary angle-closure glaucoma, secondary angle-closure glaucoma (including neovascular glaucoma), retrobulbar tumor, thyroid eye disease, Sturge-Weber Syndrome, or any other type of condition that may cause elevated episcleral venous pressure.; Contraindication (non-coverage): Hydrus Microstent is contraindicated for persons with birth defects of the anterior chamber angle of the eye, primary angle-closure glaucoma, secondary angle-closure glaucoma (including neovascular glaucoma), malignant glaucoma, traumatic glaucoma, and uveitic glaucoma.; Coding restriction: Goniotomy should not be coded in addition to other angle surgeries, stent insertions, or Schlemm canal implants, or if the incision into the trabecular meshwork is minimal or simply incidental to another procedure. Claims may be denied when the requested service falls under these.

Source

Aetna CPB 0484 — Glaucoma Surgery

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Coverage disclaimer

This page summarizes Aetna clinical-coverage criteria extracted from policy CPB 0484 for educational purposes. Coverage policies change and vary by individual plan. Always verify against Aetna's current policy before performing a procedure or submitting a claim. d3rx is not responsible for claim denials or reimbursement issues.