In my prior editorial for Glaucoma Physician, I described a draft local coverage determination (LCD) from the WPS Health Solutions Medicare Administrative Contractor (MAC) that threatened to remove surgical options for glaucoma physicians.1 As I sat to write this issue’s editorial, the final LCD ruling was released ahead of schedule,2 so I thought I would weigh in on the ruling and its implications.
Paradoxically, the popularity of minimally invasive glaucoma surgery (MIGS) and a rise in case volume are likely why insurers do not want to cover it. The bar continues to rise for coverage. Twenty years ago, an experimental procedure may have had solid clinical rationale but only been performed a few times. Now, a procedure with many studies supporting outcomes might be considered experimental if there are no prospective or prospective randomized studies to support its use. This is problematic, because now these studies are prohibitively expensive for companies. The growing number of companies in the MIGS space has made this even more challenging. If 10 instruments for goniotomy are made by 10 small companies, who is going to fund a goniotomy study? Companies sharing common CPT codes could potentially co-fund studies to support reimbursement and category 1 CPT code designation.
According to the recent LCD, the WPS Medicare contractors will continue to pay for goniotomy with cataract surgery, with certain caveats: “The patient is currently being treated with an ocular hypotensive medication procedure and is at high risk for vision loss due to uncontrolled IOP and being performed in conjunction with cataract surgery.”2 However, the MAC also states that the patient can’t have advanced glaucoma, which of course is where every patient described above is heading. Canaloplasty is now considered experimental, which boggles my mind. Cyclophotocoagulation has now also been designated for refractory cases only, although many surgeons appropriately use it earlier.
Among other obvious mistakes, the document refers to MIGS as “MIGs” throughout, because the authors have no understanding of the subject matter. The authors described the GATT procedure as experimental when it performs a goniotomy, which they have deemed to have sufficient evidence. A similar mistake was made with the Omni procedure where the LCD document describes the combined canaloplasty and goniotomy of Omni as experimental, without clarifying that Omni performs goniotomy alone, which should be considered covered.
In summary, MIGS remains under attack. It is unfortunate that those depriving patients of these procedures do not understand what they are, how they are performed, or even what MIGS stands for. We all need to work together to protect glaucoma patients. GP
References
- Radcliffe NR. From the editor: Medicare contractors attack vulnerable glaucoma patients. Ophthalmology Management. 2023;27(Glaucoma Physician September 2023):5-6. https://www.glaucomaphysician.net/issues/2023/september-2023/from-the-editor-medicare-contractors-attack-vulner
- Centers for Medicare & Medicaid Services. Micro-Invasive Glaucoma Surgery (MIGS). Accessed October 30, 2023. https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=39620&ver=3