Prior Authorization
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Glaucoma Surgery (Mitomycin C-augmented Trabeculectomy)
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According to the most recent guidelines from (CG034, ver. 9) there are two criteria that must be met for this plan to consider Glaucoma Surgery (Mitomycin C-augmented trabeculectomy) medically necessary:
1. Diagnosis
The member has a documented diagnosis of primary open-angle glaucoma
2. Failure of Medical Management
An adequate trial of first-line (e.g., latanoprost or timolol) AND second-line (e.g., brimonidine or dorzolamide) medications have failed to control intraocular pressure
Fetching electronic health record for: Maria Klopp (7746536) from
Criterion 1 - Diagnosis
Evidence from health records
A diagnosis of advanced primary open angle glaucoma was made on 3/15/24 by Dr René Descartes at UCSF Medical Centre.
Criterion 2 - Failure of Medical Management
Evidence from health records
The patient was commenced on topical latanoprost and brinzolamide to both eyes on 3/15/24 by Dr René Descartes at UCSF Medical Centre. After 24 hours IOPs had decreased to 28 mmHg (right eye) and 21 mmHg (left eye). Visual acuity had improved to 6/60 in the right eye, and 6/5 in the left eye. Although there had been a good percentage reduction in IOP with medication, due to the advanced glaucomatous damage a lower target pressure was required and therefore medical management was deemed inadequate
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Benefits & Coverage Verification
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Maria Klopp 02/14/1983
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Policy Details
| Name | Maria Klopp |
| DOB | 02/14/1983 |
| Insurance | Oscar Health |
| Policy Number | OH773268641 |
| Group Number | 33627 |
| Effective Date | 07/23/2024 |
| Expiration Date | 07/23/2025 |
| In-Network | Yes |
Coverage Verified
Reasoning
Active in-network policy found for Maria Klopp, DOB 02/14/1983 with Oscar Health
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