Oxervate (cenegermin) for neurotrophic keratitis — Coverage Criteria
Customize your policy alerts
Sign up for Blue Cross Blue Shield - Iowa Policy 05.02.73 alerts
Get alerted when Policy 05.02.73 changes without checking for updates manually.
Monitor payer policy activity
This policy governs coverage and authorization criteria for Oxervate (recombinant human nerve growth factor, cenegermin) for treatment of neurotrophic keratitis for Wellmark Blue Cross and Blue Shield members in Iowa. It applies when benefits exist under the member's contract and exclusions do not apply.
No material clinical or coverage changes in this revision.
Coverage Criteria for Oxervate (cenegermin)
Initial therapy coverage criteria
Covered when ALL of the following are met
Services are subject to the member's contract terms. Benefits are payable only when the applicable contract provides coverage and no exclusions, limitations, or exceptions apply. Wellmark will determine medical necessity only if the benefit exists under the member's contract; individual member benefits must be verified and this policy may not apply to certain programs (e.g., FEP).
Use of Oxervate in disease stages other than Stage 2 or Stage 3, or when there is not a documented persistent epithelial defect (PED) or corneal ulceration of at least 2 weeks' duration refractory to one or more conventional non‑surgical treatments, and/or without documented decreased corneal sensitivity in at least one corneal quadrant, does not meet the coverage criteria and is considered not covered under this policy.
Procedures, Codes, and Quantity Limits
| No codes listed |
Provider Requirements and Prior Authorization
Prior authorization required documenting Stage 2–3 disease and eligibility
Prior authorization is required for Oxervate and must document that the member has Stage 2 or Stage 3 neurotrophic keratitis with a persistent epithelial defect (PED) or corneal ulceration of at least 2 weeks' duration refractory to one or more conventional non‑surgical treatments, that there is evidence of decreased corneal sensitivity in at least one corneal quadrant, and that the member has not previously received an 8‑week course of Oxervate in the affected eye. Authorizations may be granted for up to 16 weeks (8 weeks therapy per eye).
- Must meet all coverage criteria: refractory PED/ulcer ≥2 weeks, decreased corneal sensitivity (method and quadrant documented), and no prior 8‑week Oxervate course in the affected eye.
- Approvals may be for up to 16 weeks (8 weeks therapy per eye) and are subject to age and dosing limits per FDA labeling.
Step requirement — trial and failure of conventional non‑surgical therapy
Before Oxervate will be authorized, the provider must document failure of one or more conventional non‑surgical treatments (for example, preservative‑free artificial tears).
- Step requirement: at least one prior conventional non‑surgical therapy attempted and refractory.
Required documentation — duration, refractoriness, and corneal sensitivity
Document the clinical duration of the epithelial defect or corneal ulcer (≥2 weeks), refractoriness to conventional non‑surgical treatments, and objective evidence of decreased corneal sensitivity including the method used and the corneal quadrant(s) involved.
- Record duration: PED or corneal ulcer ≥2 weeks refractory to prior non‑surgical treatments.
- Record decreased corneal sensitivity method (e.g., cotton swab, Cochet‑Bonnet, CRCERT‑Belmonte) and at least one quadrant with reduced sensation.
- Document prior treatment history to confirm no previous 8‑week Oxervate course in the affected eye and that quantity limits (8 kits per affected eye lifetime) will not be exceeded.
Triggers for denial — missing or conflicting eligibility documentation
Absence of required documentation will trigger denial — specifically, lack of documentation of a persistent epithelial defect or corneal ulcer ≥2 weeks refractory to conventional non‑surgical treatments, absence of documented decreased corneal sensitivity in at least one corneal quadrant, or prior receipt of an 8‑week Oxervate course in the affected eye.
- Denial triggers: no record of PED/ulcer ≥2 weeks refractory to conventional non‑surgical therapy.
- Denial triggers: no documentation of decreased corneal sensitivity (method and quadrant).
- Denial triggers: documentation shows prior 8‑week Oxervate course in the affected eye.
Background
Oxervate (cenegermin) is a recombinant human nerve growth factor indicated for the treatment of neurotrophic keratitis. It is intended for use in patients with Stage 2 or Stage 3 disease who have a persistent epithelial defect or corneal ulceration of at least 2 weeks' duration refractory to one or more conventional non‑surgical treatments, and who have documented decreased corneal sensitivity in at least one corneal quadrant. Authorization may be granted for up to 16 weeks (typically 8 weeks of therapy per affected eye) when all coverage criteria are met.
Key Definitions
Revision History
Policy reviewed (annual review).
Current effective date set for the policy.
Policy originally became effective.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.