A Proposed Medicare Policy Would Tie Our Hands in the Fight Against Glaucoma

As an ophthalmic practice administrator, I see every day what it takes to deliver the interventional glaucoma care necessary to preserve sight. It is not a simple cookie-cutter approach. A proposed Medicare policy would make it harder still, replacing physician judgment with a rigid, one-size-fits-all sequence that ignores how differently this disease behaves from patient to patient.

What the LCDs Would Restrict

Five Medicare Administrative Contractors (MACs) have similar Local Coverage Determinations (LCDs) in the proposal stage and available for comment through July 4. At issue is coverage of the intracameral travoprost implant (iDose TR, Glaukos). If the LCDs become finalized, Medicare would not cover the procedural pharmaceutical unless patients first fail both a trial of selective laser trabeculoplasty (SLT) and two topical medications. The LCD would also bar physicians from placing the implant during a MIGS procedure, whether that MIGS procedure is performed alone or in combination with cataract surgery.

If finalized, the LCDs would take decision-making out of the hands of physicians and replace individualized judgment with a fixed treatment sequence applied to every patient.

One Treatment Pathway Does Not Fit Every Patient

Glaucoma is a heterogeneous disease. It presents and progresses differently in each patient, and physicians need a full range of options to treat each case individually. These LCDs run counter to that reality, grouping every patient into a single, one-size-fits-all pathway. As stated above, the policy would force a failed trial of SLT and two topical medications before coverage. This leaves no room for individualized care plans at the start of treatment, reducing every patient to the same generic approach. As for the failed SLT requirement specifically, nobody disputes that SLT has its place. The objection is to making it a forced, universal prerequisite, because SLT may not be appropriate for every patient—that is for the treating physician to decide. Turning it into a mandatory gateway for every patient is not a logical for practices managing glaucoma.

Similar rigidity shows up in how the policy treats procedures that could otherwise be performed together. Rather than allowing physicians to combine treatment in a single visit, reimbursement rules would force additional trips to the OR, additional preoperative visits, additional anesthesia, additional cost, and a worse experience for the patient.

The LCD’s Drop-First Requirement Ignores Patient Psychology and Physical Challenges Patients with glaucoma face known difficulties with topical medication. A glaucoma drop regimen can be challenging to manage, even for the most motivated patients, due to a range of factors, such as cost, side effects, and forgetfulness. Further, many patients have physical limitations that prevent them from administering drops correctly, such as arthritis, tremor, or limited dexterity. It is also difficult for physicians to discern how compliant patients are with their eye drops outside the clinic.1 The practical result is that patients on drop therapy alone are more likely to be lost to follow-up, which puts them at risk of their glaucoma progressing unchecked.2 In our own practice, return-to-follow-up rates are substantially higher among glaucoma patients on procedural pharmaceuticals than among those managed on drops alone.

The Longer-Term Costs the LCDs Are Not Counting

Delaying effective interventional glaucoma treatments does not just risk a patient’s vision. It risks a patient's independence and their livelihood. Vision loss from progressive and uncontrolled glaucoma is debilitating with links to cognitive decline, depression, and reduced quality of life, all of which carry their own significant costs to Medicare down the line. For a patient still in the workforce, the cost is personal as well as systemic: What is the cost to someone with 10 or 12 years of professional life left who can no longer work because of preventable blindness?

How to Protect Your Medicare Patients’ Access to Care

Glaucoma care has moved toward individualized, patient-centered treatment, and for good reason: Physicians need the ability to use tools like iDose TR confidently, as part of an individualized interventional glaucoma protocol built around what each patient needs. These proposals would move us backward, replacing clinical judgment with a fixed algorithm that delays inevitable interventions, disproportionately harming the patients who struggle most with drops, and raising the risk of preventable blindness.

If you think the proposed LCDs would impact patients at your practice, click here to learn more and submit a comment before the July 4 deadline.