CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Intravitreal and Punctum Corticosteroid Implants | Medical Coverage Policy

Defines medical necessity coverage positions for intravitreal corticosteroid implants (fluocinolone acetonide 0.59 mg Retisert, 0.19 mg Iluvien, 0.18 mg Yutiq; dexamethasone 0.7 mg Ozurdex) and punctal dexamethasone insert (Dextenza 0.4 mg) for Medicare Advantage and Commercial products, plus procedure/drug billing codes and applicable ICD-10 diagnoses.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyIntravitreal and Punctum Corticosteroid Implants | Medical Coverage Policy

Policy CodePolicy N/A

Change TypeClarifiedNew CPT code noted

Effective DateOct 1, 2015

Next Review Date

Key ActionFile covered J-/CPT codes with an approved ICD-10 diagnosis from the listed codes and verify member coverage; prior authorization is not required.

SourceLink

POLICY UPDATE CHANGES

Inclusion of CPT 68841 for punctal implant with effective date 1/01/2022 noted.

Prior authorization review is not required.

6Indications listed as medically necessary

9Not covered / not medically necessary uses

NoPrior authorization required

68841New CPT code effective 2022

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Coverage Summary

Scope: Defines medical necessity coverage positions for intravitreal corticosteroid implants (fluocinolone acetonide 0.59 mg Retisert, 0.19 mg Iluvien, 0.18 mg Yutiq; dexamethasone 0.7 mg Ozurdex) and a punctal dexamethasone insert (Dextenza 0.4 mg) for Medicare Advantage and Commercial products, and lists procedure/drug billing codes and applicable ICD-10 diagnoses. Policy status: CURRENT. Effective date: 2015-10-01; Last review: 2023-03-15.

Policy metadata

PayerBlue Cross & Blue Shield (policy document)

Policy TitleIntravitreal and Punctum Corticosteroid Implants (Medical Coverage Policy)

Policy Number

Effective Date2015-10-01

Last Review2023-03-15

Next Review

StatusCURRENT

6Indications listed as medically necessary

9Specific uses listed as not covered / not medically necessary

1Prior authorization required (1=yes, 0=no) — policy states prior auth is not required

Medically Necessary and Coverage Criteria

Medically Necessary (Medicare Advantage Plans and Commercial Products)

A device may be considered medically necessary when any of the following indications are met:

ANY of the following

Fluocinolone acetonide intravitreal implant 0.59 mg (Retisert) for chronic non-infectious intermediate, posterior, or panuveitis
Fluocinolone acetonide intravitreal implant 0.19 mg (Iluvien) for diabetic macular edema in individuals previously treated with a course of corticosteroids and who did not have a clinically significant rise in intraocular pressure
Dexamethasone intravitreal implant 0.7 mg (Ozurdex) for noninfectious ocular inflammation or uveitis affecting the intermediate or posterior segment of the eye
Dexamethasone intravitreal implant 0.7 mg (Ozurdex) for macular edema following branch or central retinal vein occlusion

Coding

Covered HCPCS/J-codes and CPTmixedCovered

J7311	Fluocinolone acetonide, intravitreal implant
J7312	Injection, dexamethasone, intravitreal implant, 0.1 mg
J7313	Injection, fluocinolone acetonide, intravitreal implant, 0.01 mg
J7314	Injection, fluocinolone acetonide, intravitreal implant (Yutiq), 0.01 mg
68841	Insertion of drug-eluting implant, including punctal dilation when performed, into lacrimal canaliculus, each (New code effective 1/01/2022)

Applicable ICD-10 diagnoses (must be filed with covered codes)ICD-10

D18.09
E08.37
E09.37
E10.37
E11.37
E13.37
H20.10-H20.13
H30.90-H30.93
H34.8110-H34.8192
H34.8310-H34.8392

1–10 of 15

1/2

Note: CPT 68841 (Insertion of drug-eluting implant into lacrimal canaliculus) is listed as a new code effective 1/01/2022. Covered J-/CPT codes must be filed with an approved ICD-10 diagnosis from the listed ICD-10 code set on the policy.

Provider Actions and Billing Notes

Documentation Required

Diagnosis required on claim

Covered J-/CPT codes must be filed with an approved ICD-10 diagnosis from the listed codes; benefits may vary by contract so verify member coverage.

J7311
J7312
J7313
J7314
68841

Prior Authorization

Prior authorization not required

Prior authorization review is not required.

Background and Evidence Summary

Background: Intravitreal implants reviewed include fluocinolone acetonide (Retisert 0.59 mg; Iluvien 0.19 mg; Yutiq 0.18 mg) and dexamethasone (Ozurdex 0.7 mg). Fluocinolone implants are nonerodible and deliver drug for up to 30–36 months; dexamethasone intravitreal implants are bioerodible and last up to 6 months. A punctum intracanalicular dexamethasone insert (Dextenza 0.4 mg) is reviewed for sustained release to the ocular surface. Clinical contexts reviewed include uveitis, macular edema (including diabetic macular edema and retinal vein occlusion–related macular edema), and postoperative inflammation (eg, following ophthalmic/cataract surgery).

Indication / Study focus	Evidence summary
Uveitis - fluocinolone 0.59 mg	Multiple RCTs showed prevention of recurrence and improved visual acuity over 4 years but increased cataract and glaucoma risk; evidence sufficient for meaningful improvement
Dexamethasone 0.7 mg - uveitis	RCT showed reduced inflammation and clinically meaningful vision improvement at 8 weeks; higher cataract and IOP risk; evidence sufficient
Dexamethasone 0.7 mg - macular edema (RVO)	Two RCTs showed clinically meaningful short-term visual acuity improvements within 1–3 months; benefits not sustained at 180 days in some studies; evidence sufficient
Fluocinolone 0.59 mg - diabetic macular edema (refractory)	RCT showed greater proportion with clinically significant vision improvement at 6 months but substantial cataract and IOP adverse events; evidence insufficient overall
Fluocinolone 0.19 mg - diabetic macular edema	Two RCTs showed clinically meaningful improvements at 2–3 years with high cataract and IOP incidence; evidence sufficient for meaningful improvement
Dexamethasone 0.7 mg - diabetic macular edema	Three RCTs showed clinically meaningful vision improvements peaking at 3 months and maintained with retreatment to 39 months; evidence sufficient
Punctum dexamethasone insert 0.4 mg (Dextenza) - postoperative inflammation and pain	Three RCTs showed significant improvements in absence of pain at 8 days and absence of anterior chamber cells at day 14; adverse events similar to sham; evidence sufficient

Definitions:

• Intravitreal implant: A drug delivery system injected or surgically implanted in the vitreous for sustained release to the posterior/intermediate segments of the eye.

• Punctum implant: A drug delivery device inserted through the lower lacrimal punctum into the canaliculus for sustained release to the ocular surface.

Revision History

clarified

Prior authorization review is not required.

2022-01-01clarifiedLatest

Inclusion of CPT 68841 for insertion of a drug-eluting punctal implant (new code effective 1/01/2022).