In May 2026, 5 Medicare Administrative Contractors (MACs)—First Coast Service Options, National Government Services, Noridian Healthcare Solutions, Palmetto GBA, and Wisconsin Physicians Service—released proposed Local Coverage Determinations (LCDs) addressing Medicare reimbursement for anterior-segment intraocular nonbiodegradable drug-eluting systems, a category that currently includes only the travoprost intracameral implant iDose TR (Glaukos). 

The proposed LCDs would consider implantation medically reasonable and necessary only after patients have (1) failed medical management, generally defined as failure of at least 2 topical medications or intolerance or inability to use them, and (2) failed selective laser trabeculoplasty (SLT). The proposals also state that the implant may not be placed concurrently with another ophthalmic surgery or procedure, except cataract surgery; prohibit readministration within 2 years; and require that all coverage criteria still be met when implantation is performed during cataract surgery. 

Concerned physicians, the American Glaucoma Society, and other stakeholders submitted written comments or testified during the public comment period, which ended July 4, 2026. Many glaucoma specialists believe the proposed LCDs do not reflect contemporary glaucoma practice or the clinical rationale underlying sustained drug-delivery therapies. Glaucoma Physician spoke with several leading surgeons about the proposed LCDs, the reasons for their concerns, and the changes they believe would better reflect contemporary glaucoma practice.

Starting From the Wrong Premise

Steven R. Sarkisian Jr., MD

Oklahoma Eye Surgeons

I think the proposed LCD starts from a premise that isn’t correct. Even though the FDA approval is very clear, the coverage policy appears to treat procedural pharmaceuticals as though they were another MIGS procedure rather than a pharmaceutical therapy. That fundamentally misunderstands what procedural pharmaceuticals are and how they fit into the glaucoma treatment algorithm. They are sustained drug-delivery therapies, not another surgical procedure.

Because of that, many of the downstream recommendations don’t make sense. They are based on assumptions about how these therapies should be used that don’t reflect contemporary glaucoma practice or the intended role of sustained drug delivery.

I hope that, through the public comment process, policy makers come to understand that it’s not simply a matter of disagreeing with individual provisions of the proposal. The underlying premise itself needs to be reconsidered. If the starting point is incorrect, then many of the resulting coverage restrictions will also be inappropriate.

Ultimately, coverage policies should reflect what these therapies actually are, how they were evaluated by the FDA, and how physicians use them in clinical practice. If we begin with the correct understanding of procedural pharmaceuticals, I think we can develop policies that are much more consistent with both the available evidence and the needs of our patients.

Interventional Glaucoma Requires Flexibility

I. Paul Singh, MD

The Eye Centers of Racine and Kenosha, Wisconsin

I understand where the MACs are coming from, but I don’t think they fully appreciate the value of this class of therapy or how we actually use it in clinical practice. This “wait and progress first” attitude is the antithesis of interventional glaucoma.

The most important basic understanding is that the proposed LCDs are lumping procedural pharmaceuticals into the MIGS world. Procedural pharmaceuticals are not a MIGS device or MIGS procedure. They are pharmaceutical agents. Just like we use topical medications after glaucoma surgery, this is simply another way of delivering medication.

That’s why I think the proposal gets combination therapy wrong. Many patients who undergo MIGS are back on medications within a few years. If we have the opportunity to place sustained drug delivery at the same time as a MIGS procedure, we may prevent them from going back on to topical drops, reduce compliance issues, and avoid bringing them back later for another procedure. Instead, the proposal says, perform the MIGS procedure first; then, if the patient ends up back on drops and can’t tolerate them, bring them back for another surgery. That’s another incision, another procedure, more operating room time, and more cost.

I also don’t think absolute treatment requirements reflect real-world glaucoma care. There’s an art to glaucoma treatment. Not every patient is the same, and there are situations where SLT or multiple topical medications aren’t the right next step.

One Size Does Not Fit All

Manjool M. Shah, MD

Kellogg Eye Center, Michigan

We’re blessed with this era of interventional glaucoma, in which we have an increased awareness of the need to proactively treat this blinding disease. We have a dramatic increase in tools to deliver safe and effective care for patients that allow them to live their lives relatively unhindered by the burdens of glaucoma management. Any attempt to restrain patient access and physician autonomy to make appropriate choices is troubling, in my opinion.

This is not an issue specific to one technology. We have tools that are FDA approved. They have passed the muster of evidence that allowed them to be placed in our hands. It is frustrating to have restrictions applied to the use of these technologies when we know they can help patients.

SLT is a really great first-line therapy for a lot of patients with glaucoma, and by no means do I want to disparage SLT. I use it all the time as a primary therapy. But the reality is that not every patient is a good candidate for SLT. Very often we’ll start with SLT and then go to something like a procedural pharmaceutical. But to apply a one-size-fits-all rule restricts access for patients who may not be candidates for one modality but are candidates for another.

A similar argument could be made regarding the restriction on using procedural pharmaceuticals at the same time as another MIGS procedure. Having the opportunity to address both pathways during a single procedure—with one trip to the operating room, one set of incisions, and one set of risks—makes more sense for the right patient than doing a procedure, realizing that it’s insufficient, and then bringing the patient back later for another.

We know these procedures are safe. We know they’re working through different mechanisms, and we know glaucoma itself involves multiple mechanisms. So let’s meet patients where they are and deliver care in the safest possible package.

Evidence Should Drive Coverage Policy

Savak “Sev” Teymoorian, MD, MBA

Harvard Eye Associates, California

We want to practice evidence-based medicine. That’s why the FDA is so critical about the studies for any new therapies. The FDA carefully reviews the data and makes recommendations about how these products should be used. Those recommendations should be followed.

The same standard should apply to LCDs. When LCDs make comments like, “You have to do SLT,” or “You have to try 2 drops first,” there aren’t studies showing those things. They’re simply making blanket requirements.

I’m all about following the evidence. If there were evidence showing patients should receive a particular treatment first, then I’m all for it. But you can’t just make random requirements. Why is it 2 drops? The LCD doesn’t even specify what categories of drops. Why must everyone have SLT first? Some patients aren’t even appropriate candidates for SLT.

I would rather see recommendations than requirements. And if you’re going to make a requirement, then make the requirement evidence based. Otherwise, all we’re doing is setting these therapies back. These proposed LCDs will force physicians to wait before addressing the patient’s needs aggressively. I don’t wait until my colon has a problem before I get a colonoscopy. I don’t wait until my teeth are damaged before I see the dentist. Why should glaucoma be different?

We have products that work. We have evidence behind them. Yet these proposed LCDs are creating a system where patients have to do poorly before we can offer them something that may help.

The Cost of Delayed Treatment  

Christine Funke, MD

Barnet Dulaney Perkins Eye Center, Arizona

The recent LCD proposal has the potential to impact best practice for glaucoma patients by limiting available treatment modalities. The requirement that patients first fail 2 topical medications and SLT before becoming eligible for sustained drug delivery opens a Pandora’s box around medication nonadherence, unnecessary disease progression, and loss to follow-up. Patients may ultimately spend years on topical therapy before a treatment that bypasses adherence can even be considered.

The diurnal curve also becomes problematic when evaluating the proposed criterion for medication success—a 20% to 30% reduction in IOP. This assumes that the IOP measured in the clinic reflects IOP throughout the day and night, when, in reality, IOP fluctuates, often more significantly in patients with glaucoma and during sleeping hours. As a result, determining whether medications are truly successful becomes much more difficult, particularly given the well-known issue of medication nonadherence. This may further extend the period during which a patient is believed to be adequately controlled when, in reality, visual field loss continues to progress, creating a scenario in which avoidable vision loss could occur before non-topical treatment options become available.

If medications are required, their bioavailability also varies considerably over a 24-hour period, unlike iDose TR. This creates yet another disadvantage while patients work through the required steps to access continuous drug delivery. Given the known fluctuations in IOP, physicians recognize that treatments providing consistent IOP reduction throughout the day and night are more likely to improve overall IOP control.

Align Policy With Patient Care    

Philip S. Garza, MD, MSc

Thomas Eye Center, Georgia

One of the biggest challenges in glaucoma care is that there is often a disconnect between treatment efficacy under ideal conditions and treatment effectiveness in the real world. Sustained-release procedural pharmaceuticals were developed to address that specific clinical gap. Coverage policies should recognize that distinction and preserve access for appropriately selected patients.

Most glaucoma specialists would agree that there is no single treatment sequence that is appropriate for every patient. Drops, SLT, sustained-release pharmaceuticals, MIGS, and filtering procedures each solve different clinical problems and often complement one another.

Coverage policies are most effective when they establish reasonable safeguards while still allowing physicians to individualize care based on disease severity, adherence risk, ocular surface health, patient preferences, and other clinical factors. Policies that require multiple mandatory treatment failures before a physician can access another evidence-based option may create unintended consequences. Additional office visits, repeated medication changes, prior authorizations, staged procedures, and prolonged observation periods all consume resources for practices and patients alike. More importantly, they may delay reliable IOP control in a disease in which vision loss is irreversible.

I think everyone involved shares the same objective: protecting Medicare beneficiaries while ensuring responsible stewardship of health care resources. The opportunity is to develop coverage policies that are evidence-based, clinically practical, and sufficiently flexible to accommodate the diversity of patients we see in everyday glaucoma practice. In my view, preserving physician judgment for appropriately selected patients ultimately serves both those goals. GP