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Prior Authorization

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:

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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

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Criterion 1 - Diagnosis

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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

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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

Maria Klopp 02/14/1983

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Policy found, verifying coverage

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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

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Reasoning

Active in-network policy found for Maria Klopp, DOB 02/14/1983 with Oscar Health

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