Intracameral Implants (Requires Preauthorization)
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Policy governing preauthorization and medical necessity criteria for one-time intracameral drug-eluting implants (bimatoprost/Durysta and travoprost/iDose TR) to reduce intraocular pressure in patients with open-angle glaucoma or ocular hypertension.
No material clinical or coverage changes in this revision.
Coverage Criteria for Intracameral Implants
Durysta (bimatoprost) — Covered when ALL criteria are met
One-time intracameral injection (bimatoprost (Durysta)) may be scientifically validated when ALL the following are met:
All items are required
iDose TR (travoprost) — Covered when ALL criteria are met
One-time intracameral implant (travoprost (iDose TR)) may be scientifically validated when ALL the following are met:
All items are required
All other indications for intracameral drug-eluting implants that are not specifically listed as covered with criteria (Durysta or iDose TR) are considered investigational.
When the specified product-specific medical necessity criteria for intracameral implants are not met, the requested services are considered investigational.
Coding and Dose Limits
Preauthorization, Documentation, and Denial Triggers
Prior medication trials required
Prior therapeutic trials are required: the patient must have tried and failed or be intolerant/contraindicated to at least one topical ophthalmic prostaglandin AND at least one topical beta-adrenergic blocker before implantation.
- Examples of topical prostaglandins: bimatoprost, latanoprost, travoprost.
- Examples of topical beta-adrenergic blockers: betaxolol, metipranolol, timolol.
Required documentation for preauthorization
Documentation submitted for preauthorization must demonstrate patient age, prior trial and failure or intolerance/contraindication to at least one topical prostaglandin and one topical beta-adrenergic blocker, that the implant will be administered only to the affected eye, no prior same-product treatment to the affected eye, and that the planned dose does not exceed the product-specific per-eye maximum.
- Age: patient is 18 years of age or older.
- Prior treatments: details of trials, failures, or intolerance/contraindication to prostaglandin and beta-blocker therapies.
- Eye-specific details: confirmation the procedure is for the affected eye and that the affected eye has not previously received the same product (Durysta or iDose TR).
- Dose: planned dose must not exceed 10 mcg bimatoprost per eye (Durysta) or 75 mcg travoprost per eye (iDose TR).
Denial triggers for medical necessity
Request may be denied if the intracameral implant does not meet ALL specified criteria for the named product, including age ≥18, required prior medication trials/intolerance, eye-specific use, no prior same-product treatment to the affected eye, and adherence to per-eye dose limits.
- Durysta denial triggers include prior treatment of the affected eye with bimatoprost or dose exceeding 10 mcg per eye.
- iDose TR denial triggers include prior treatment of the affected eye with travoprost (iDose TR) or dose exceeding 75 mcg per eye.
- Requests not meeting the required prior trials or for indications other than open-angle glaucoma or ocular hypertension are considered investigational.
Definitions
Background
Intracameral implants are sterile, sustained-release drug delivery devices placed in the anterior chamber of the eye to provide localized, extended therapeutic effect aimed at reducing intraocular pressure with reduced systemic exposure and improved adherence. These devices may be biodegradable or non-biodegradable and are designed for single-administration placement to deliver prostaglandin-class medication directly to the target eye.
Durysta (bimatoprost) is a biodegradable intracameral implant FDA-approved as a single administration option to lower intraocular pressure in adults with open-angle glaucoma or ocular hypertension; iDose TR (travoprost) is an intracameral travoprost implant that received FDA single‑administration approval with demonstrated early intraocular pressure reduction in clinical studies. Use is subject to product‑specific coverage criteria and preauthorization.
Revision History
Policy became effective on 2026-06-01.
Policy was last reviewed on 2026-02-04.
Next scheduled review date set for 2027-02-03.
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