MA Intracameral Implants (Preauthorization Required)
Customize your policy alerts
Sign up for Blue Cross Blue Shield - Nebraska Policy M.58 alerts
Get alerted when Policy M.58 changes without checking for updates manually.
Monitor payer policy activity
Covers one-time intracameral bimatoprost (Durysta) and travoprost (iDose TR) implants for reducing intraocular pressure in adults with open-angle glaucoma or ocular hypertension and specifies preauthorization requirements and clinical criteria for medical necessity.
No material clinical or coverage changes in this revision.
Coverage Criteria
Bimatoprost (Durysta) criteria
One-time intracameral bimatoprost (Durysta) implant may be considered reasonable and necessary when ALL criteria below are met:
ALL of the following
- Patient is 18 years of age and older
- Patient has tried and failed or is intolerant to at least one topical ophthalmic prostaglandin (e.g., bimatoprost, latanoprost, travoprost)
- Patient has tried and failed or is intolerant or has a contraindication to at least one topical beta-adrenergic blocker (e.g., betaxolol, metipranolol, timolol)
- Injection/implant will be administered only to the affected eye
- Affected eye has not received prior treatment with bimatoprost (Durysta)
- Dose does not exceed 10 mcg bimatoprost per affected eye
Travoprost (iDose TR) criteria
One-time intracameral travoprost (iDose TR) implant may be considered scientifically validated when ALL criteria below are met:
ALL of the following
- Patient is 18 years of age and older
- Patient has tried and failed or is intolerant to at least one topical ophthalmic prostaglandin (e.g., bimatoprost, latanoprost, travoprost)
- Patient has tried and failed or is intolerant or has a contraindication to at least one topical beta-adrenergic blocker (e.g., betaxolol, metipranolol, timolol)
- Injection/implant will be administered only to the affected eye
- Affected eye has not received prior treatment with travoprost (iDose TR)
- Dose does not exceed 75 mcg travoprost (iDose TR) per affected eye
Not reasonable and necessary / Not covered
Non-covered circumstances
ALL of the following
- Services that do not meet the above criteria are considered not reasonable and necessary
- All other indications are considered not reasonable and necessary
Procedure and Coding
| 0660T | Implantation of anterior segment intraocular nonbiodegradable drug-eluting system, internal approach |
| 0661T | Removal and reimplantation of anterior segment intraocular nonbiodegradable drug-eluting implant |
| J7351 | Injection, bimatoprost intracameral implant, 1 microgram |
| J7355 | Injection, travoprost intracameral implant, 1 microgram |
Provider Actions and Requirements
Preauthorization required; medical necessity criteria must be met
Preauthorization is required for intracameral implants as indicated in the policy title; approval is contingent on meeting the listed medical necessity criteria for the specified product (bimatoprost Durysta or travoprost iDose TR). The criteria include: patient age ≥18, prior trial and failure or intolerance to at least one topical prostaglandin and at least one topical beta-adrenergic blocker (or contraindication), administration only to the affected eye, no prior treatment of the affected eye with the same intracameral product, and adherence to the product-specific dose limit (10 mcg bimatoprost per affected eye; 75 mcg travoprost per affected eye).
- Patient is 18 years of age and older.
- Tried and failed or intolerant to at least one topical ophthalmic prostaglandin (e.g., bimatoprost, latanoprost, travoprost).
- Tried and failed or intolerant or contraindicated to at least one topical beta-adrenergic blocker (e.g., betaxolol, metipranolol, timolol).
- Injection/implant administered only to the affected eye.
- Affected eye has not received prior treatment with the same intracameral product (Durysta or iDose TR).
- Dose does not exceed 10 mcg bimatoprost or 75 mcg travoprost per affected eye, as applicable.
High denial risk if criteria or indications are not met
Services that do not meet the above specified criteria or other indications are considered not reasonable and necessary and therefore are likely to be denied.
- If any of the product-specific criteria (age, prior therapies, laterality, prior same-drug exposure, dose limits) are not met, the service is not considered reasonable and necessary.
- All other indications beyond those listed for Durysta and iDose TR are considered not reasonable and necessary.
Definitions and Product Examples
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.