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