CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Ocriplasmin (intravitreal) for vitreomacular adhesion/traction — Coverage Criteria

This policy governs coverage for a single intravitreal injection of ocriplasmin (Jetrea) to treat symptomatic vitreomacular adhesion (VMA) or vitreomacular traction (VMT) for BlueCHiP for Medicare and Commercial products; other uses including repeat injections are not covered.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyOcriplasmin (intravitreal) for vitreomacular adhesion/traction — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 10, 2015

Next Review DateN/A

Key ActionSubmit billing with HCPCS J7316 and an appropriate ICD-10 code in the range H43.821-H43.829 when claiming coverage for a single intravitreal injection.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

single injectioncovered treatment per eye

J7316HCPCS

H43.821-H43.829ICD-10 range

repeat injectionsnoncovered

30%spontaneous release rate

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria

Medically necessary indication

Covered when ALL of the following are met

Primary coverage criteria: Single intravitreal injection of ocriplasmin for an eye with symptomatic vitreomacular adhesion (VMA) or vitreomacular traction (VMT)single injection per eye

Covered for both BlueCHiP for Medicare and Commercial Products per policy text

The use of intravitreal ocriplasmin is considered not covered/not medically necessary in all other situations beyond the single-injection indication described in this policy. This exclusion explicitly includes any repeat injections of ocriplasmin.

Repeat injections of ocriplasmin are explicitly not covered/not medically necessary under this policy and should not be billed as a covered service.

Coding

Covered HCPCSHCPCSCovered

J7316

Injection, Ocriplasmin, 0.125 mg

Associated ICD-10-CM codes (range)ICD-10

H43.821-H43.829

ICD-10-CM range for vitreous conditions associated with VMA/VMT

Provider Actions & Requirements

Prior Authorization

Prior Authorization Required

Not applicable

Note

Observation Before Intervention

Observe patients with symptomatic vitreomacular adhesion (VMA) or vitreomacular traction (VMT) for possible spontaneous release prior to intervention; spontaneous release occurs in about 30% of cases over 1–2 years, so observation is usually indicated unless clinical worsening warrants treatment.

Spontaneous release rate ~30% over 1–2 years
Consider observation before vitrectomy or injection unless symptoms progress

Documentation Required

Billing / Coding Documentation

Background

Ocriplasmin is a recombinant protease administered by a single intravitreal injection to induce vitreous liquefaction and separation from the retina for symptomatic vitreomacular adhesion (VMA) and vitreomacular traction (VMT). The vitreous normally adheres to the retinal surface; therapeutic separation is intended to relieve traction that causes decreased or distorted central vision. Because ocriplasmin is provided as a single-dose intravitreal injection, the policy limits coverage to one injection per eye.

Definitions

Vitreomacular adhesion (VMA) — key facts

DefinitionVitreomacular adhesion (VMA): adhesion at the macula without detectable changes in retinal morphology.

Clinical contextMay be focal or diffuse and can cause symptoms such as decreased visual acuity, metamorphopsia, or central field defect.

Natural historyOften observed because spontaneous release occurs in about 30% of cases over 1–2 years.

Implication for treatmentObservation is usually indicated until resolution or worsening; vitrectomy is standard if symptoms worsen or persist.

Vitreomacular traction (VMT) — key facts

DefinitionVitreomacular traction (VMT): adhesion at the macula with retinal morphologic changes but without full-thickness macular hole.