Fighting the MIGS insurance battle

Two surgeons share their approach to minimally invasive glaucoma surgery and the level of influence that insurance and reimbursement have on their decision-making.

“It’s the economy, stupid”

By Michael Patterson, DO

That famous saying, which has been used for the better part of two and a half decades, has plagued our great country. And this is the same exact problem we face in ophthalmology today.


In 2019, no one sends a patient home with glasses without correcting astigmatism. Not one practice. Why is this? Because the patient needs it. But how many of you haven’t placed a toric IOL in the eye during cataract surgery with a known astigmatic patient? Everyone’s hands go up. Why do we not place torics in everyone with astigmatism? The answer isn’t as simple as “the patient doesn’t want them.” Often, patients do not know whether they have astigmatism until we tell them. They just want to see clearly. So, we are willing to take their cataract out and not place a lens that will make them see more clearly?

The reason for this is the toric IOL is not provided in the United States for the same cost as a standard monofocal IOL — insurance companies do not cover this type of treatment. Therefore, we give patients a monofocal and force them into glasses rather than pay for the toric lens for the patient ourselves. My practice, however, has participated in ASCRS’ Operation Sight, a program designed to help those who do not have insurance or cannot afford insurance have the opportunity to see again with cataract surgery. Through the ASCRS foundation, money is sent to the practice for the patient to have surgery at a very nominal fee.

Charity work is one thing, but when it comes to torics or minimally invasive glaucoma surgery (MIGS) vs. drops vs. economy of one’s practice, it is not a charity work.


Glaucoma surgery truly is all about the economy. The advent of MIGS has revolutionized glaucoma surgery. These therapies have changed glaucoma from a “sit on the sideline” disease to an interventional disease. Many surgeons are treating every patient with glaucoma with a MIGS device of some kind (and rightfully so). But why are some surgeons either not adopting MIGS or only using certain devices? It’s the economy, stupid!

Companies have produced amazing technologies in the world of glaucoma that transform lives like never before. Can you imagine a world in which the trabeculectomy is extinct? I can, but not before we get paid for these procedures.

Many insurance companies do not pay for certain “investigational” devices, even though the FDA has cleared the device. In these cases, the physician is the one responsible for taking all the risk of trying a new product in health care. There is never an ability to “test-drive the car” per se. Instead, companies ask the surgeons to take the risk of buying devices for thousands of dollars (often inducing one to purchase large quantities). Then, the companies tell surgeons that they hope they will get paid. This is a bit short-sided to say it mildly.

With increasing cuts to reimbursement, including some MIGS procedures now paying a physician fee of less than $200 per procedure, the inherent financial risks to one’s practice are not worth the cost of the reimbursement.


We have obligations to our patients, and we have obligations to our staff and practices. Typically, there are other alternatives to these new devices. For instance, many MIGS devices have preexisting codes. Why not use these rather than risk the practice’s financial health? By not being fiscally responsible, you are not only putting your practice’s net revenue on the line but ultimately the people who work for you as well.

There has to be a balance, obviously, but we are not talking about deciding whether to drain a retrobulbar hemorrhage on a noninsured patient. We are talking about deciding whether a patient uses latanoprost QHS OU or not. The safety profile of MIGS devices is impeccable, but the IOP reductions are not always that appealing — nor is it appealing for the surgeon to not be paid for the use of the device.


This all boils down to whether you are in a system where you are the physician and responsible for paying the bills. If you are in a practice where your salary is not affected by the productivity of your job, then you are less likely to worry about each individual cost coming out of your clinic — you have no incentive to be cost conscious. But, if you are in a situation like mine in which you get paid what you produce directly, then you are much more likely to take the cost-effective approach — unless the situation is deemed emergent for the patient.

I would love to see the folks who say, “we just do what is best for our patients,” start putting toric lenses in for free. I think the staff would eventually revolt when the revenue of the practice started drying up. OM

About the Author

Not about what insurance says is “right”

By Russell Swan, MD

Minimally invasive glaucoma surgery (MIGS) has transformed the landscape of glaucoma care over the past decade and provided a much-needed option for so many of our patients. Insurance coverage of these procedures, while better, still presents challenges at times.


In understanding the issues around reimbursement for MIGS treatments, it is important to clarify the meanings of on label, off label and third-party reimbursement. “On label” means the FDA and manufacturer have used data collected to negotiate a label that describes indications, effectiveness and safety parameters. “Off label” indicates a drug or device is used outside the strict negotiated label of the FDA. Of note, many procedures and treatments considered the standard of care are “off label,” such as amniotic membrane use after cataract surgery.

Third-party reimbursement is a much more nebulous process and involves ongoing partnership and discussion between companies, physicians, CMS and third-party payers. Third-party reimbursement often trails FDA approval by many years after the continued accumulation of well-established data and experience. Outside the glaucoma space, corneal cross-linking is a great example of this process. Despite FDA approval and more than 10 years of data from Europe, it took many insurance carriers months to years to begin providing coverage for this service.


As physicians, we did not take an oath to insurance companies or an oath to the FDA. We took an oath to our patients and profession.

A very simple question that I ask for every patient is, “What would I do if this was my eye?” This question cuts through the “noise” of labeling and reimbursement and allows me to clearly understand what I feel is best for the patient in front of me. It is important to note that sometimes what is best for a patient’s eye may not be best for the patient’s life. Many times, a patient simply cannot afford the “ideal” approach to care, which is unfortunate. This does not mean we should not have a discussion with our patient, advocate to our patient’s insurance carrier and track our long-term outcomes to help future patients.


A great example of this is my approach to patients with cataract and moderate to severe primary open angle glaucoma (POAG). Given the poor long-term outcomes reported in the Tube Versus Trabeculectomy study,1 I feel strongly that if I had cataract and severe POAG I would prefer having a combined MIGS surgery (canaloplasty and trabecular meshwork stent placement) prior to incisional surgery. Because of the labeling of stents for mild or moderate disease, this can sometimes present coverage challenges. I recently presented our five-year data on the use of MIGS in patients with severe POAG at ASCRS in which we found that we have been able to avoid incisional surgery in more than 90% of patients.2 A similar coverage challenge can often be seen with stenting-based procedures in pseudophakic patients as well.

If payers will not cover the cost of a trabecular meshwork stent in severe disease, a second stent or use in pseudophakia, should patients have the option to cover the cost? Absolutely. Should physicians, ASCs or hospitals bear the costs in these situations? I would argue no. We are providing a service to patients, and, after clear and transparent education about their surgical options as well as the costs associated with those options, patients should be able to select and pay for the option they and their doctor feel is best for their eyes. In our practice, this involves a strong financial informed consent, attempt to garner insurance coverage and the use of an Advance Beneficiary Notice of Noncoverage if needed.


In today’s world of MIGS offerings, we are fortunate to have a bevy of options that allow us to reach similar treatment goals while tailoring our approach if financial considerations are at play. By becoming comfortable in the MIGS space and having familiarity with trabecular meshwork stent placement, ab interno canaloplasty techniques, goniotomy techniques and endocyclophotocoagulation, we can modify our approach to provide a minimally invasive offering for each of our patients. We should advocate for our patients and always approach each patient interaction with a simple question: “What would I do if this was my eye?” OM


  1. Gedde SJ, Schiffman JC, Feuer WJ, et al. Treatment outcomes in the Tube Versus Trabeculectomy (TVT) study after five years of follow-up. Am J Ophthalmol. 2012;153:789-803.e2.
  2. Swan R, et al. Trabecular microbypass stent implantation with cataract surgery in severe POAG: 5 year results. Paper presented at: ASCRS Conference; May 2019; San Diego, CA.

About the Author