Glaucoma denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/ Case Summary: The enrollee requested coverage for Ex-Press Glaucoma Filtration Device, Hydrus Microstent, or iStent Trabecular or Inject Trabecular Micro-Bypass Stent. The health plan has denied this test as experimental/investigational. According to the medical record, the patient was diagnosed with glaucoma, cataracts, macular degeneration, bilateral retinal hemorrhage, ocular hypertension, hypertension, atrial fibrillation, and diabetes mellitus. He has been using eye drops including BromSite, Durezol, and Combigan for intraocular pressure. The clinical note indicates the patient presented for cataract evaluation to the right eye. The patient stated that the vision in the right eye had been getting worse for six months at all distances with a lot of glare at night and with bright sun. Both eyes were dry.

Nature of Statutory Criteria/Case Summary: An enrollee has requested iStent surgery for treatment of her glaucoma. Three physician reviewers found that in the peer-reviewed medical literature, Wellik and Dale demonstrated that the micro-bypass stent is a relatively safe procedure, with limited complications and no serious adverse sequelae. Samuelson and colleagues reported that pressure reduction on fewer medications was clinically and statistically significantly better one year after iStent with cataract surgery versus cataract surgery alone, with an overall safety profile similar to that of cataract surgery alone. Craven and colleagues found that patients with combined single trabecular micro-bypass stent and cataract surgery had significantly better intraocular pressure control on no medication through two years when compared to patients who underwent cataract surgery alone.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the anterior segment optical coherence tomography (OCT) services. The standard therapy for this patient with glaucoma suspicion is comprehensive ophthalmologic examination with the addition of gonioscopy to evaluate the anterior chamber angle. Anterior chamber OCT has been reviewed and assessed for its usefulness by the American Academy of Ophthalmology (AAO). Although the AAO did not take a final position on the usefulness of this imaging, the Technology Assessment committee concluded that “there have been no appropriately powered longitudinal clinical studies demonstrating that imaging can be used to predict the future development of primary angle closure (PAC)”.

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for Combigan 0.2% - 0.5% drops. Findings: The physician reviewer found that Combigan is a combination of timolol 0.5% and brimonidine 0.2%. The main advantage of the using combination drop is the convenience since the same IOP lowering effect can be achieved with using the same medication (timolol and brimonidine) as single agents. The standard practice would be to prescribe timolol and brimonidine as separate drops. Alternatively, there are other combination drops that are covered by the Health Plan (Cosopt or Simbrinza) which could also be used instead with similar efficacy. The documentation provided did not indicate an intolerance to the drops that are covered by the Health Plan.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving glaucoma, then check the rights and deadlines that apply to your plan.