Ocriplasmin Medical Policy
Defines medical necessity for a single intravitreal injection of ocriplasmin for treatment of an eye with symptomatic vitreomacular adhesion (VMA) or vitreomacular traction (VMT) for Medicare Advantage and commercial products; states repeat injections and all other uses are not covered/not medically necessary.
No material changes to clinical coverage or policy criteria; existing indications and restrictions remain unchanged.
Coverage Summary
Overview: This policy defines medical necessity for a single intravitreal injection of ocriplasmin for treatment of an eye with symptomatic vitreomacular adhesion (VMA) or vitreomacular traction (VMT) for both Medicare Advantage and Commercial products. The policy stance is mixed: a single injection for symptomatic VMA/VMT may be considered medically necessary when criteria are met, but repeat injections and all other uses are not covered/not medically necessary. The covered HCPCS code is J7316 (Injection, Ocriplasmin, 0.125 mg).
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