CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Ocriplasmin (intravitreal) for symptomatic vitreomacular adhesion/traction - Coverage Criteria

Defines Blue Cross & Blue Shield of Rhode Island coverage stance for a single intravitreal injection of ocriplasmin to treat symptomatic vitreomacular adhesion (VMA) or vitreomacular traction (VMT) for applicable members.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyOcriplasmin (intravitreal) for symptomatic vitreomacular adhesion/traction - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 10, 2015

Next Review DateN/A

Key ActionVerify member benefits and, if covered, bill HCPCS J7316 with an appropriate ICD-10 diagnosis from H43.821-H43.829 for a single intravitreal injection.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

single injectioncovered dosing event

repeat injectionsnot covered

J7316billing code

H43.821-H43.829diagnosis range

30%spontaneous release (1-2 yr)

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Coverage Criteria

Initial (single) injection — medically necessary

Covered when ALL of the following are met

Coverage conditions: Single intravitreal injection of ocriplasmin is considered medically necessary for treatment of an eye with symptomatic vitreomacular adhesion (VMA) or vitreomacular traction (VMT).

Applies to BlueCHiP for Medicare and Commercial Products per policy statements.

Not medically necessary / Not covered

Not covered / not medically necessary

Non-covered uses: Use of intravitreal ocriplasmin in all other situations, including repeat injections, is considered not covered or not medically necessary.

Policy explicitly disallows repeat injections and other non-specified uses.

Repeat injections of intravitreal ocriplasmin and any use other than treatment of symptomatic vitreomacular adhesion (VMA) or vitreomacular traction (VMT) are excluded from coverage. The policy specifies that only a single intravitreal injection may be considered medically necessary for symptomatic VMA/VMT; subsequent or repeat administrations are not covered or considered medically necessary.

For Commercial Products, a single intravitreal injection of ocriplasmin may be considered medically necessary for treatment of an eye with symptomatic VMA or VMT. The use of intravitreal ocriplasmin is considered not medically necessary in all other situations, including use of repeat injections of ocriplasmin.

For BlueCHiP for Medicare, a single intravitreal injection of ocriplasmin may be considered medically necessary for treatment of an eye with symptomatic VMA or VMT. The use of intravitreal ocriplasmin is considered not covered in all other situations, including use of repeat injections of ocriplasmin.

Coding

Covered HCPCSHCPCSCovered

J7316

Injection, Ocriplasmin, 0.125 mg

Associated ICD-10-CM diagnosis rangeICD-10

H43.821-H43.829

ICD-10-CM range associated with vitreoretinal conditions (listed in policy)

Provider Actions and Billing Guidance

Prior Authorization

Prior authorization requirement

Prior authorization requirement: Not applicable for this policy; no prior authorization is required for a single intravitreal injection of ocriplasmin when the member meets the coverage criteria for BlueCHiP for Medicare or Commercial Products. Note that repeat injections are not covered.

Single injection only — repeat injections are not covered

Note

Benefit verification

Verify member-specific benefits and plan coverage before providing treatment. Coverage and benefit limitations (including medical necessity determinations) may vary by group or contract; check the member’s Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable benefits.

Confirm medical and not medically necessary / not covered benefits for the member's contract
Confirm any additional authorization, step therapy, or prior-notification requirements that may apply under the member’s plan

Background

Ocriplasmin is a recombinant, truncated form of human plasmin administered as an intravitreal injection to cleave protein components at the vitreoretinal interface and promote vitreous liquefaction and separation from the retina. It is intended as a single-injection treatment to induce release of symptomatic vitreomacular adhesion (VMA) or vitreomacular traction (VMT). Observation is also a management option because spontaneous release of VMA/VMT occurs in approximately 30% over 1–2 years, and pars plana vitrectomy remains the standard surgical alternative when necessary.

Definitions

Ocriplasmin (inv-13): drug key facts

Generic nameOcriplasmin

Molecular descriptionRecombinant truncated form of human plasmin (proteolytic enzyme)

Route and dosing eventIntravitreal injection as a single dose

Mechanism / intended actionBreaks down protein components at the vitreoretinal interface to induce vitreous liquefaction and separation from the retina

VMA vs VMT (inv-14): definitions

Vitreomacular adhesion (VMA)Adhesion of the vitreous at the macula without detectable retinal morphologic changes

Vitreomacular traction (VMT)

Revision History

2019-05-21policy_updatedLatest

Policy last updated; document indicates a policy update on this date.

2015-10-01effective_date

Policy effective date established for this coverage document.

2019-08provider_communication

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyOcriplasmin (intravitreal) for symptomatic vitreomacular adhesion/traction - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 10, 2015

Next Review DateN/A

Key ActionVerify member benefits and, if covered, bill HCPCS J7316 with an appropriate ICD-10 diagnosis from H43.821-H43.829 for a single intravitreal injection.

SourceLink

On This Page

Billing Rule

Billing linkage

Billing linkage: Bill HCPCS J7316 (Injection, Ocriplasmin, 0.125 mg) with an appropriate diagnosis code from ICD-10-CM range H43.821–H43.829 (vitreomacular adhesion / traction codes). Ensure claims reflect a single injection and the covered diagnosis to avoid denial.

HCPCS: J7316 — Injection, Ocriplasmin, 0.125 mg
ICD-10-CM: H43.821-H43.829 — use an appropriate code in this range for symptomatic VMA/VMT

Denial Risk

Denial triggers

Denial triggers: Claims may be denied when documentation shows repeat injections, use for indications other than symptomatic vitreomacular adhesion (VMA) or vitreomacular traction (VMT), or when member benefits do not cover the service. Ensure clinical documentation supports a single intravitreal injection for symptomatic VMA/VMT.

Repeat injections of ocriplasmin — not covered/not medically necessary
Use for indications other than symptomatic VMA/VMT — not covered/not medically necessary
Lack of member benefit coverage or missing supporting documentation may lead to denial

Adhesion of the vitreous at the macula with retinal morphologic changes but without a full-thickness macular hole

Clinical relevanceBoth VMA and VMT may be focal or diffuse and can cause symptoms (diminished acuity, metamorphopsia, central field defect); observation is common due to ~30% spontaneous release over 1–2 years

Provider Update published in August 2019 referencing this policy's publication/communications history.

2018-11provider_communication

Provider Update published in November 2018 referencing this policy's publication/communications history.

2017-06provider_communication

Provider Update published in June 2017 referencing this policy's publication/communications history.

2016-10provider_communication

Provider Update published in October 2016 referencing this policy's publication/communications history.

2015-08provider_communication

Provider Update published in August 2015 referencing this policy's publication/communications history.