Intravitreal Implants (ARCHIVED)

Policy ID: I-78-032

Section: Injections

Effective Date: October 01, 2019

Revised Date: October 25, 2024

Revision Effective Date: December 08, 2024

Last Reviewed: November 19, 2024

Applies To: Commercial Only

This policy has been Archived effective December 08, 2024. Click the Archive tab above for more information.

Policy ID: I-78-032

Section: Injections

Effective Date: October 01, 2019

Revised Date: October 25, 2024

Revision Effective Date: December 08, 2024

Last Reviewed: November 19, 2024

Archived Date: December 08, 2024

Applies To: Commercial Only

Description

An intravitreal implant is a drug delivery system, injected or surgically implanted in the vitreous of the eye, for sustained release of drug to the posterior and intermediate segments of the eye. Intravitreal corticosteroid implants are being investigated for a variety of inflammatory eye conditions.

An intravitreal implant may be an acceptable alternative in individuals who are intolerant or refractory to other therapies or in individuals who are judged likely to experience severe adverse events from systemic corticosteroids.

Policy Application

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

A dexamethasone intravitreal implant (Ozurdex™) may be considered medically necessary for individuals 18 years of age or older for the treatment of ANY ONE of the following criteria:

Macular edema following branch retinal vein occlusion (BRVO); or
Macular edema following central retinal vein occlusion (CRVO); or
For the treatment of non-infectious uveitis affecting the posterior segment of the eye; or
For the treatment of diabetic macular edema.

All other uses of a corticosteroid intravitreal implant are considered not medically necessary.

Procedure Code

J7312

Fluocinolone acetonide (Iluvien®) may be considered medically necessary in individuals 18 years of age or older when they meet ALL of the following criteria:

Individual has a diagnosis of diabetic macular edema; and
Individual received a previous course of corticosteroids without experiencing a clinically significant rise in intraocular pressure; and
Dose is for no more than one (1) implant per eye.

All other uses of a fluocinolone acetonide (Iluvien) intravitreal implants are considered not medically necessary.

Procedure Code

J7313

Fluocinolone acetonide (Retisert®) may be considered medically necessary for the treatment of chronic noninfectious uveitis affecting the posterior segment of the eye in individuals 12 years of age or older.

All other uses of a fluocinolone acetonide (Retisert) intravitreal implants are considered not medically necessary.

Procedure Code

J7311

Fluocinolone acetonide (Yutiq™) may be considered medically necessary for the treatment of chronic noninfectious uveitis affecting the posterior segment of the eye in individuals 18 years of age or older.

All other uses of a fluocinolone acetonide (Yutiq) intravitreal implants are considered not medically necessary.

Procedure Code

J7314

Dexamethasone punctum insert (Dextenza®) may be considered medically necessary for individuals 18 years of age or older for the treatment of ANY ONE of the following criteria:

Ocular inflammation and pain following ophthalmic surgery; or
Ocular itching associated with allergic conjunctivitis after treatment failure with all of the following unless contraindicated:
- Topical ophthalmic antihistamines; and
- Topical ophthalmic mast cell stabilizers; and
- Topical ophthalmic corticosteroids.

All other uses of a corticosteroid punctum insert are considered not medically necessary.

Procedure Code

J1096

NOTE: In addition to the above criteria, product specific dosage and/or frequency limits may apply in accordance with the United States Food and Drug Administration (U.S. FDA)-approved product prescribing information, national compendia, Centers for Medicare and Medicaid Services (CMS) and other peer reviewed resources or evidence-based guidelines.

Diagnosis Codes

Covered diagnosis codes for procedure code J7311

H30.001

H30.002

H30.003

H30.009

H30.011

H30.012

H30.013

H30.019

H30.021

H30.022

H30.023

H30.029

H30.031

H30.032

H30.033

H30.039

H30.041

H30.042

H30.043

H30.049

H30.101

H30.102

H30.103

H30.109

H30.111

H30.112

H30.113

H30.121

H30.122

H30.123

H30.129

H30.131

H30.132

H30.133

H30.139

H30.141

H30.142

H30.143

H30.149

H30.21

H30.22

H30.23

H30.811

H30.812

H30.813

H30.891

H30.892

H30.893

H30.91

H30.92

H30.93

H44.111

H44.112

H44.113

Covered diagnosis codes for procedure code J7312

E08.311

E08.3211

E08.3212

E08.3213

E08.3219

E08.3311

E08.3312

E08.3313

E08.3319

E08.3411

E08.3412

E08.3413

E08.3419

E08.3511

E08.3512

E08.3513

E08.3519

E09.311

E09.3211

E09.3212

E09.3213

E09.3219

E09.3311

E09.3312

E09.3313

E09.3319

E09.3411

E09.3412

E09.3413

E09.3419

E10.311

E10.3211

E10.3212

E10.3213

E10.3219

E10.3311

E10.3312

E10.3313

E10.3319

E10.3411

E10.3412

E10.3413

E10.3419

E10.3511

E10.3512

E10.3513

E10.3519

E10.3591

E10.3592

E10.3593

E10.3599

E11.311

E11.3211

E11.3212

E11.3213

E11.3219

E11.3311

E11.3312

E11.3313

E11.3319

E11.3411

E11.3412

E11.3413

E11.3419

E11.3511

E11.3512

E11.3513

E11.3519

E13.311

E13.3211

E13.3212

E13.3213

E13.3219

E13.3311

E13.3312

E13.3313

E13.3319

E13.3411

E13.3412

E13.3413

E13.3419

E13.3511

E13.3512

E13.3513

E13.3519

H30.001

H30.002

H30.003

H30.009

H30.011

H30.012

H30.013

H30.019

H30.021

H30.022

H30.023

H30.029

H30.031

H30.032

H30.033

H30.039

H30.041

H30.042

H30.043

H30.049

H30.101

H30.102

H30.103

H30.109

H30.111

H30.112

H30.113

H30.121

H30.122

H30.123

H30.129

H30.131

H30.132

H30.133

H30.139

H30.141

H30.142

H30.143

H30.149

H30.21

H30.22

H30.23

H30.811

H30.812

H30.813

H30.891

H30.892

H30.893

H30.91

H30.92

H30.93

H34.8110

H34.8120

H34.8130

H34.8190

H34.8310

H34.8320

H34.8330

H34.8390

H44.111

H44.112

H44.113

Covered diagnosis codes for procedure code J7313

E08.311

E08.3211

E08.3212

E08.3213

E08.3219

E08.3311

E08.3312

E08.3313

E08.3319

E08.3411

E08.3412

E08.3413

E08.3419

E08.3511

E08.3512

E08.3513

E08.3519

E09.311

E09.3211

E09.3212

E09.3213

E09.3219

E09.3311

E09.3312

E09.3313

E09.3319

E09.3411

E09.3412

E09.3413

E09.3419

E10.311

E10.3211

E10.3212

E10.3213

E10.3219

E10.3311

E10.3312

E10.3313

E10.3319

E10.3411

E10.3412

E10.3413

E10.3419

E10.3511

E10.3512

E10.3513

E10.3519

E10.3591

E10.3592

E10.3593

E10.3599

E11.311

E11.3211

E11.3212

E11.3213

E11.3219

E11.3311

E11.3312

E11.3313

E11.3319

E11.3411

E11.3412

E11.3413

E11.3419

E11.3511

E11.3512

E11.3513

E11.3519

E13.311

E13.3211

E13.3212

E13.3213

E13.3219

E13.3311

E13.3312

E13.3313

E13.3319

E13.3411

E13.3412

E13.3413

E13.3419

E13.3511

E13.3512

E13.3513

E13.3519

Covered diagnosis codes for procedure code J7314

H30.001

H30.002

H30.003

H30.009

H30.011

H30.012

H30.013

H30.019

H30.021

H30.022

H30.023

H30.029

H30.031

H30.032

H30.033

H30.039

H30.041

H30.042

H30.043

H30.049

H30.101

H30.102

H30.103

H30.109

H30.111

H30.112

H30.113

H30.121

H30.122

H30.123

H30.129

H30.131

H30.132

H30.133

H30.139

H30.141

H30.142

H30.143

H30.149

H30.21

H30.22

H30.23

H30.811

H30.812

H30.813

H30.891

H30.892

H30.893

H30.91

H30.92

H30.93

H44.111

H44.112

H44.113

Covered diagnosis codes for procedure code J1096

G89.18

H01.111

H01.112

H01.113

H01.114

H01.115

H01.116

H01.119

H10.45

H57.10

H57.11

H57.12

H57.13

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 9-26-2019 Adopted policy

Internal Medical Policy Committee 9-21-2020 Annual review; no clinical content changed

Internal Medical Policy Committee 1-19-2021 Revision

Removed 'adult' replace with '18 years of age or older'

Internal Medical Policy Committee 1-20-2022 Annual review, no clinical content change

Internal Medical Policy Committee 3-23-2022 Coding update

Added procedure code, 68841, to the policy

Internal Medical Policy Committee 9-28-2022 Revision

Updated fluocinolone acetonide (Iluvien) criteria, and
Added dexamethasone punctum insert (Dextenza) criteria and covered diagnosis codes to the policy, and
Removed all procedure codes

Internal Medical Policy Committee 9-12-2023 - Effective October 30, 2023

Changed experimental/investigational statement throughout the policy to not medically necessary

Internal Medical Policy Committee 9-17-2024 Effective November 04, 2024

Annual review no clinical content change

Internal Medical Policy Committee 11-19-2024 Effective December 08, 2024

Archived policy

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Medical Policies Quick Search

Intravitreal Implants (ARCHIVED)

This policy has been Archived effective December 08, 2024. Click the Archive tab above for more information.

Description

Policy Application

Criteria

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer