TL;DR: Aetna, a CVS Health company, modified CPB 0484 governing glaucoma surgery coverage, effective January 15, 2026. Here's what changes for billing teams.
This update to the Aetna glaucoma surgery coverage policy refines medical necessity criteria across a wide range of surgical procedures — from micro-bypass stents to goniotomy coding rules — and adds explicit guidance on CPT 65820 that will directly affect claim denial rates if your team isn't prepared. The policy covers CPT codes including 65820, 65855, 66180, 66183, 66989, 66991, 0449T, and 0450T, plus HCPCS codes C1783, J7315, and L8612, among dozens more. If your practice bills glaucoma surgery for Aetna members, audit your charge capture before January 15, 2026.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna, a CVS Health company |
| Policy | Glaucoma Surgery – CPB 0484 |
| Policy Code | CPB 0484 |
| Change Type | Modified |
| Effective Date | January 15, 2026 |
| Impact Level | High |
| Specialties Affected | Ophthalmology, Ambulatory Surgery Centers, Outpatient Hospital |
| Key Action | Audit CPT 65820 billing and confirm MIGS procedures are coded only in conjunction with cataract surgery (CPT 66989/66991) |
Aetna Glaucoma Surgery Coverage Criteria and Medical Necessity Requirements 2026
The CPB 0484 Aetna glaucoma surgery coverage policy draws a clear line between what's medically necessary and what's experimental. That line runs through specific device approvals, drug failure thresholds, and procedure combinations. Get the criteria wrong and you're looking at denials on high-dollar surgical claims.
First-Line and Second-Line Drug Failure Is a Hard Requirement
For laser trabeculoplasty (CPT 65855) and FDA-approved aqueous drainage implants (CPT 66180, 66183, HCPCS C1783, L8612), Aetna requires documented failure of both first-line drugs — such as latanoprost or timolol — and second-line drugs — such as brimonidine or dorzolamide — before the procedure is medically necessary. This isn't a soft preference. It's a step-therapy requirement, and missing documentation of that failure is a fast path to a claim denial.
Approved drainage devices under this policy include the Ahmed glaucoma implant, Baerveldt seton, Ex-PRESS mini glaucoma shunt, Glaucoma pressure regulator, Krupin-Denver valve implant, Molteno implant, and Schocket shunt. Coverage applies when the member has refractory primary open-angle glaucoma and drug therapy has failed. Document both conditions explicitly in the record.
MIGS Devices: Coverage Tied to Cataract Surgery
The iStent Trabecular Micro-Bypass Stent (one or two per eye, CPT 0449T or 0450T) and the Hydrus Microstent are medically necessary only when performed in conjunction with cataract surgery — billed as CPT 66989 or 66991. The member must have mild or moderate open-angle glaucoma, a concurrent cataract, and be currently using an ocular hypotensive medication.
This is the most financially significant part of the policy for ASCs and ophthalmology practices. These devices carry real reimbursement value, and billing them outside of a combined cataract procedure will trigger denial. If your surgeons are placing iStents as standalone procedures, that's a coverage issue, not a billing issue — but your billing team will be the one catching the fallout.
XEN Glaucoma Treatment System
The XEN Glaucoma Treatment System (coded under CPT 66183) is medically necessary for refractory glaucoma when previous surgical treatment has failed. It also covers primary open-angle glaucoma and pseudoexfoliative or pigmentary glaucoma with open angles that are unresponsive to maximum tolerated medical therapy. Document the prior surgical failure or maximum tolerated therapy status before billing.
Adjunctive Anti-Fibrotic Agents
Mitomycin C (HCPCS J7315) is covered — but only when used with the Ex-PRESS mini glaucoma shunt. Use it with any other shunt implant and Aetna considers it experimental. That's a narrow carve-out that's easy to miss if your OR staff documents mitomycin use generically without tying it to the specific device.
Goniotomy and CPT 65820: The New Coding Guidance
This is where the 2026 update gets specific and operationally consequential. Aetna now incorporates CMS 2025 guidance on goniotomy coding directly into CPB 0484.
CPT 65820 (goniotomy) is medically necessary for glaucoma treatment. But the policy is explicit: CPT 65820 should not be billed in addition to other angle surgeries, stent insertions, or Schlemm canal implants. It also should not be billed when the incision into the trabecular meshwork is minimal or simply incidental to another procedure.
Multiple goniopunctures — with or without tissue excision — do not meet the CPT description for a true goniotomy. This clarification directly addresses a pattern Aetna and CMS have flagged. If your coders are billing CPT 65820 alongside 0449T or 0450T, or using it to describe goniopuncture, expect retroactive audits after January 15, 2026.
Trabeculotomy (CPT 65850) follows the same medically necessary designation for glaucoma. Both goniotomy and trabeculotomy are experimental for all other indications.
Combined Glaucoma and Cataract Surgery
Combined glaucoma and cataract surgery (CPT 66989 or 66991) is medically necessary when the member has a visually significant cataract with glaucoma that remains uncontrolled despite maximal medical therapy and/or laser trabeculoplasty. Prior authorization requirements may apply — verify with the specific plan before scheduling.
Aetna Glaucoma Surgery Exclusions and Non-Covered Indications
The experimental and investigational list in CPB 0484 is long and growing. These are the designations your billing team needs to know before a procedure hits your charge capture.
Ab interno procedures are largely non-covered. Ab interno Kahook dual blade trabeculectomy for primary congenital glaucoma is experimental. Ab interno trabeculectomy via trabectome (CPT 0253T) is experimental for glaucoma treatment generally. CPT codes 0621T and 0622T (trabeculostomy ab interno by laser) fall under the Kahook dual blade category with no specific covered indications.
AI-based diagnostic tools for glaucoma diagnosis, management, or progression detection are experimental. If your practice is billing for AI-assisted glaucoma analysis, that's not covered under this policy.
Beta radiation for glaucoma treatment is experimental. CPT codes 77401 through 77412 and HCPCS G6001 through G6014 (radiation treatment delivery) are all explicitly non-covered for glaucoma indications under CPB 0484.
Drug-eluting ocular inserts — CPT 0444T, 0445T, and HCPCS 68841 — are not covered. Neither is intraocular bevacizumab (HCPCS C9257) or anti-VEGF agents generally (J0178, J2503, J2778).
Canaloplasty combined with cataract surgery via ab interno approach is experimental. CPT 0474T falls in the non-covered group.
Adjunctive corticosteroids (HCPCS J0702, J1020, J1030, J1040, J1094, J1100, J1700, J1710, J1720, J2650, J2920, J2930, J3301) with shunt implants other than the Ex-PRESS mini glaucoma shunt are not covered. CPT 1012T (motorized ab interno trephination) is not covered.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Laser trabeculoplasty for refractory POAG after drug failure | Covered | CPT 65855 | Requires failure of first- and second-line drugs |
| FDA-approved aqueous drainage/shunt implants for refractory POAG | Covered | CPT 66180, 66183; HCPCS C1783, L8612 | Drug failure documentation required |
| iStent (1–2 per eye) with cataract surgery | Covered | CPT 0449T, 0450T, 66989, 66991 | Must be combined with cataract surgery; ocular hypotensive med required |
| Hydrus Microstent with cataract surgery | Covered | CPT 66989, 66991; HCPCS C1783 | Same criteria as iStent |
| XEN Glaucoma Treatment System | Covered | CPT 66183 | Refractory glaucoma or maximum tolerated medical therapy failure |
| Mitomycin C with Ex-PRESS mini glaucoma shunt | Covered | HCPCS J7315 | Covered only with Ex-PRESS; experimental with all other shunts |
| Combined glaucoma and cataract surgery | Covered | CPT 66989, 66991 | Visually significant cataract + uncontrolled glaucoma on max therapy |
| Goniotomy for glaucoma | Covered | CPT 65820 | Cannot be billed with angle surgery, stent insertion, or Schlemm canal implants |
| Trabeculotomy for glaucoma | Covered | CPT 65850 | External approach; experimental for non-glaucoma indications |
| VisionGraft patch graft | Covered | Integral to procedure billing | Considered integral to glaucoma treatment |
| Ab interno Kahook dual blade trabeculectomy (congenital glaucoma) | Experimental | CPT 0621T, 0622T | Not covered |
| Ab interno trabeculectomy (trabectome) | Experimental | CPT 0253T | Not covered for any glaucoma indication |
| AI-based glaucoma diagnosis/management tools | Experimental | — | Not covered |
| Beta radiation for glaucoma | Not Covered | CPT 77401–77412; HCPCS G6001–G6014 | Not covered for glaucoma indications |
| Drug-eluting ocular inserts | Not Covered | CPT 0444T, 0445T; HCPCS 68841 | Not covered |
| Intraocular bevacizumab (Avastin) | Not Covered | HCPCS C9257 | Not covered |
| Anti-VEGF agents (aflibercept, ranibizumab, pegaptanib) | Not Covered | HCPCS J0178, J2503, J2778 | Not covered for glaucoma |
| Adjunctive corticosteroids with shunt implants (non-Ex-PRESS) | Not Covered | HCPCS J0702, J1020–J1040, J1094–J3301 | Covered only with Ex-PRESS shunt |
| Motorized ab interno trephination | Not Covered | CPT 1012T | Not covered |
| Ab interno canaloplasty combined with cataract surgery | Experimental | CPT 0474T | Not covered |
| iStent as standalone (no cataract) | Not Covered | CPT 0671T | Coverage requires concurrent cataract surgery |
Aetna Glaucoma Surgery Billing Guidelines and Action Items 2026
The effective date is January 15, 2026. These steps are ordered by risk exposure.
| # | Action Item |
|---|---|
| 1 | Audit every CPT 65820 claim in your current workflow. Review whether your coders are billing goniotomy alongside stent insertions (0449T, 0450T) or angle surgeries. Under the updated CPB 0484 billing guidelines, that combination is explicitly incorrect. Pull a 90-day retrospective sample and check for these pairings before January 15, 2026. |
| 2 | Confirm iStent and Hydrus claims are always paired with cataract surgery CPT codes. CPT 0449T and 0450T require CPT 66989 or 66991 on the same claim. Build this as a hard edit in your charge capture system. A standalone MIGS claim will deny. |
| 3 | Document first- and second-line drug failure before billing trabeculoplasty or shunt implants. The policy requires documented failure of drugs like latanoprost, timolol, brimonidine, and dorzolamide. Missing this in the clinical record means missing medical necessity. Tell your ophthalmology team this documentation must be in the chart before the claim goes out. |
| 4 | Remove CPT 0253T, 0621T, and 0622T from your covered-procedure assumption list. These codes — ab interno trabectome and ab interno laser trabeculostomy — are experimental under CPB 0484. If your practice performs these procedures for Aetna members, expect no reimbursement and consider issuing advance beneficiary-style notices where applicable. Talk to your compliance officer about how to handle member communication before the effective date. |
| 5 | Restrict mitomycin C billing (HCPCS J7315) to Ex-PRESS mini shunt cases only. Using J7315 adjunctively with any other shunt triggers an experimental designation. Update your charge capture to flag J7315 for review when it appears alongside non-Ex-PRESS shunt codes. |
| 6 | Verify prior authorization requirements at the plan level for combined glaucoma and cataract surgery. The policy establishes medical necessity criteria, but individual Aetna plans may layer additional prior auth requirements on top. Confirm prior auth before scheduling, particularly for CPT 66989 and 66991 paired with MIGS devices. |
| 7 | Train coders on the goniotomy definition update. Multiple goniopunctures — with or without tissue excision — do not meet the CPT 65820 description. This is a coding accuracy issue, not just a coverage issue. Miscoding this procedure exposes your practice to audit risk under the new CMS 2025 guidance Aetna has incorporated into CPB 0484. |
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for Glaucoma Surgery Under CPB 0484
Covered CPT Codes (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| 0449T | CPT | Insertion of aqueous drainage device, without extraocular reservoir, internal approach, into the trabecular meshwork |
| 0450T | CPT | Insertion of aqueous drainage device, without extraocular reservoir, internal approach, into the trabecular meshwork (additional device) |
| 65820 | CPT | Goniotomy |
| 65850 | CPT | Trabeculotomy ab externo |
| 65855 | CPT | Trabeculoplasty by laser surgery |
| 66180 | CPT | Aqueous shunt to extraocular equatorial plate reservoir, external approach; with graft |
| 66183 | CPT | Insertion of anterior segment aqueous drainage device, without extraocular reservoir, external approach |
| 66185 | CPT | Revision of aqueous shunt to extraocular equatorial plate reservoir; with graft |
| 66989 | CPT | Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique, with insertion of intraocular lens prosthesis (list separately in addition to code for primary procedure) — with MIGS device |
| 66991 | CPT | Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), with insertion of intraocular lens prosthesis (list separately in addition to code for primary procedure) — with MIGS device |
Covered HCPCS Codes (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| C1783 | HCPCS | Ocular implant, aqueous drainage assist device |
| J7315 | HCPCS | Mitomycin, ophthalmic, 0.2 mg (covered with Ex-PRESS shunt only) |
| J9190 | HCPCS | Injection, fluorouracil, 500 mg |
| L8612 | HCPCS | Aqueous shunt (covered if FDA approved; DeepLight Gold Micro-Shunt and Eyepass Glaucoma Implant are not covered) |
Not Covered / Experimental CPT Codes
| Code | Type | Description | Reason |
|---|---|---|---|
| 0253T | CPT | Insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach | Not covered for glaucoma indications listed in CPB |
| 0444T | CPT | Initial placement of a drug-eluting ocular insert under one or more eyelids, including fitting, training, and eyelid swabbing | Not covered |
| 0445T | CPT | Subsequent placement of a drug-eluting ocular insert under one or more eyelids, including re-training | Not covered |
| 0474T | CPT | Insertion of anterior segment aqueous drainage device, with creation of intraocular reservoir, internal approach | Not covered |
| 0621T | CPT | Trabeculostomy ab interno by laser | Ab interno Kahook dual blade — no covered indications |
| 0622T | CPT | Trabeculostomy ab interno by laser; with use of ophthalmic endoscope | Ab interno Kahook dual blade — no covered indications |
| 0671T | CPT | Insertion of anterior segment aqueous drainage device into the trabecular meshwork, without external reservoir | Not covered |
| 1012T | CPT | Motorized ab interno trephination of sclera (sclerostomy) or trabecular meshwork (trabeculostomy) | Not covered |
| 68841 | CPT | Insertion of drug-eluting implant into lacrimal canaliculus, including punctal dilation when performed | Not covered |
| 77401–77412 | CPT | Radiation treatment delivery (12 codes) | Not covered for glaucoma indications |
Not Covered HCPCS Codes
| Code | Type | Description | Reason |
|---|---|---|---|
| C9257 | HCPCS | Injection, bevacizumab, 0.25 mg (Avastin, intraocular dose) | Not covered |
| G6001–G6014 | HCPCS | Radiation treatment delivery (14 codes) | Not covered for glaucoma indications |
| J0178 | HCPCS | Injection, aflibercept, 1 mg | Not covered |
| J0702 | HCPCS | Injection, betamethasone acetate and betamethasone sodium phosphate, per 3 mg | Not covered (adjunctive corticosteroid) |
| J1020 | HCPCS | Injection, methylprednisolone acetate, 20 mg | Not covered |
| J1030 | HCPCS | Injection, methylprednisolone acetate, 40 mg | Not covered |
| J1040 | HCPCS | Injection, methylprednisolone acetate, 80 mg | Not covered |
| J1094 | HCPCS | Injection, dexamethasone acetate, 1 mg | Not covered |
| J1100 | HCPCS | Injection, dexamethasone sodium phosphate, 1 mg | Not covered |
| J1700 | HCPCS | Injection, hydrocortisone acetate, up to 25 mg | Not covered |
| J1710 | HCPCS | Injection, hydrocortisone sodium phosphate, up to 50 mg | Not covered |
| J1720 | HCPCS | Injection, hydrocortisone sodium succinate, up to 100 mg | Not covered |
| J2503 | HCPCS | Injection, pegaptanib sodium, 0.3 mg | Not covered |
| J2650 | HCPCS | Injection, prednisolone acetate, up to 1 ml | Not covered |
| J2778 | HCPCS | Injection, ranibizumab, 0.1 mg | Not covered |
| J2920 | HCPCS | Injection, methylprednisolone sodium succinate, up to 40 mg | Not covered |
| J2930 | HCPCS | Injection, methylprednisolone sodium succinate, up to 125 mg | Not covered |
| J3301 | HCPCS | Injection, triamcinolone acetonide, per 10 mg | Not covered |
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