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.

Criteria

A dexamethasone intravitreal implant (Ozurdex™) may be considered medically necessary for adult individuals 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 experimental/investigational, and therefore, non-covered, due to lack of supporting published peer reviewed literature.

Procedure Codes

Fluocinolone acetonide (Iluvien®) may be considered medically necessary in the treatment of diabetic macular edema in adult individuals who have been previously treated with a course of corticosteroids and did not have a clinically significant rise in intraocular pressure.

All other uses of a fluocinolone acetonide (Iluvien) intravitreal implants are considered experimental/investigational and therefore non-covered, due to lack of supporting published peer reviewed literature.

Procedure Codes

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 experimental/investigational and therefore non-covered, due to lack of supporting published peer reviewed literature.

Procedure Codes

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 experimental/investigational and therefore non-covered, due to lack of supporting published peer reviewed literature.

Procedure Codes

NOTE: In addition to the above criteria, product specific dosage and/or frequency limits may apply in accordance with the U.S. Food and Drug Administration (FDA)-approved product prescribing information, national compendia, Centers for Medicare and Medicaid Services (CMS) and other peer reviewed resources or evidence-based guidelines. Blue Cross Blue Shield North Dakota may deny, in full or in part, reimbursement for utilization that does not fall within the applicable dosage and/or frequency limits.

Diagnosis Codes

Covered diagnosis code for procedure code J7311

Covered diagnosis code for procedure code J7312

Covered diagnosis code for procedure code J7313

Covered diagnosis code for procedure code J7314

Professional Statements and Societal Positions Guidelines

NA