CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Ocriplasmin (Jetrea) intravitreal injection coverage criteria

Policy governing coverage and medical necessity of a single intravitreal injection of ocriplasmin for treatment of symptomatic vitreomacular adhesion (VMA) or vitreomacular traction (VMT) for Blue Cross Blue Shield - Rhode Island members, including Medicare and commercial products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyOcriplasmin (Jetrea) intravitreal injection coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2015

Next Review DateN/A

Key ActionProvide a single intravitreal injection of ocriplasmin for symptomatic VMA or VMT when coverage criteria are met; repeat injections are not covered.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

singlecovered dose/instance

J7316billing code

H43.821-H43.829diagnosis range

noPA required

Coverage Criteria

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Medically necessary indication

Covered when ALL of the following are met

Coverage conditions for single injection: Single intravitreal injection of ocriplasmin for treatment of an eye with symptomatic vitreomacular adhesion (VMA) or vitreomacular traction (VMT)single injection

Applies to BlueCHiP for Medicare and Commercial Products

Provider Actions & Billing

Prior Authorization

Prior authorization is not required.

Denial Risk

Coverage Limitation — Single Injection Only

A single intravitreal injection of ocriplasmin may be considered medically necessary for treatment of an eye with symptomatic vitreomacular adhesion (VMA) or vitreomacular traction (VMT). The use of intravitreal ocriplasmin is considered not covered/not medically necessary in all other situations, including repeat injections of ocriplasmin.

BlueCHiP for Medicare: single intravitreal injection may be considered medically necessary for symptomatic VMA or VMT; repeat injections not covered.
Commercial products: single intravitreal injection may be considered medically necessary for symptomatic VMA or VMT; repeat injections not medically necessary.

Documentation Required

Benefit Verification

Benefits may vary between groups and contracts. Refer to the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement to determine applicable benefits and any contract-specific coverage limitations.

Note

Clinical Management Context

Standard clinical management includes observation for spontaneous release of VMA/VMT; vitrectomy is the standard surgical treatment when intervention is indicated.

Background

Ocriplasmin (Jetrea) is a recombinant truncated form of human plasmin administered as a single intravitreal injection intended to enzymatically cleave proteins at the vitreoretinal interface, producing vitreous liquefaction and separation from the retina to treat symptomatic vitreomacular adhesion (VMA) or vitreomacular traction (VMT).

Treatment with ocriplasmin is described as a single-dose pharmacologic approach to inducing posterior vitreous detachment and is proposed as an alternative to observation or surgical vitrectomy in selected symptomatic cases.

Definitions

Ocriplasmin (Jetrea) — definition and mechanism

Generic name / BrandOcriplasmin (Jetrea)

Molecular / functional classRecombinant truncated form of human plasmin (proteolytic enzyme)

Route and dosing instanceIntravitreal injection as a single dose

Mechanism of actionBreaks down proteins at the vitreoretinal interface (e.g., collagen, laminin, fibronectin) to induce vitreous liquefaction and posterior vitreous detachment

Indicated clinical useProposed for treatment of symptomatic vitreomacular adhesion (VMA) and vitreomacular traction (VMT)

VMA vs VMT — definitions

Vitreomacular adhesion (VMA)Adhesion at the macula without detectable changes in retinal morphology (no retinal morphologic changes)

Vitreomacular traction (VMT)Adhesion at the macula with retinal morphologic changes but without a full-thickness macular hole

Clinical distinction importanceVMA vs VMT classification guides management; both can be focal or diffuse and may cause symptoms like decreased acuity or metamorphopsia

Natural history noteSpontaneous release occurs in ~30% of cases over 1–2 years; observation is commonly used unless worsening prompts vitrectomy