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December 13, 2022

January 5, 2023 Multi-Jurisdictional Micro-Invasive Glaucoma Surgery (MIGS) Contractor Advisory Committee (CAC) Meeting – Key Questions

For all questions, answers must be based on clinical literature with consideration of quality of evidence to support your answer.

For All MIGS Procedures

  • How do you define failed medical management for glaucoma and when does it warrant a MIGS procedure?
  • What factors influence selection of one MIGS procedure over another one?
  • For both goniotomy and standalone stent procedures, what evidence exists that speaks to durable long-term outcomes?

For Stents as Stand-Alone Procedures

  • Do you think there is sufficient evidence to support placement of stents outside of cataract surgery for POAG?
  • What should be done in a patient with both cataract and POAG? For what type of patient will cataract extraction alone be sufficient?
  • Reviewing the evidence provided, what risks of bias would you identify, if any? Does this impact your confidence in placement of standalone stents?
  • Why are standalone stents now acceptable outside of concomitant cataract surgery?
  • What constitutes failure or success of a stent(s) procedures?
  • Is there any alternative to stents for POAG? What is the current standard of care? Where do stents fit into the therapeutic armamentarium?
  • For what type of patient will cataract extraction alone be sufficient?
  • If standalone stent surgery is considered reasonable and necessary, are all types of stents considered equivalent? Is there evidence to support placement of a single stent over multiple stents or should stents be placed serially while monitoring IOP?
  • How does surgeon experience impact success with these procedures?

For Goniotomy

  • For what types of glaucoma should goniotomy be offered as a therapy? Is ocular HTN an acceptable indication for either stents or goniotomy? Who is the optimal patient for a goniotomy and in whom should it be avoided? (Can you share any literature?)
  • How is a classic goniotomy procedure for pediatric glaucoma different from goniotomy in adults? If pediatric goniotomy is frequently a bilateral procedure, would a bilateral approach be reasonable in a Medicare population as well? What quality of evidence exists for goniotomy in the geriatric population?
  • What is the correct CPT code reporting for various devices that achieve discrete punctures or punch trephinations into the trabecular meshwork? Is there evidence to support coverage for any number of such discrete interventions? Is this type of procedure currently best reported as an unspecified/unlisted procedure?
  • What are your thoughts on adult goniotomy utilization increasing a hundred fold between 2007 and 2017?


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