iDose TR (travoprost intracameral implant) — Coverage Criteria and Prior Authorization
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Policy governing prior authorization, coverage criteria, continuation, and exclusions for iDose TR for reduction of intraocular pressure in patients with open-angle glaucoma or ocular hypertension for BlueCross BlueShield of Tennessee members.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial Therapy
Covered when ALL of the following are met
Appendix A provides minimum cell density by age and phakic status
Continuation Therapy
Continuation therapy authorization for 12 months when ALL of the following are met
If no baseline, contralateral un-implanted eye may be used; inter-eye difference must be <10%
Coverage excludes members who have any of the following conditions or contraindications: corneal endothelial dystrophy; active ocular or periocular infection; history of prior corneal transplantation; or known hypersensitivity to travoprost.
Use of iDose TR for indications other than open-angle glaucoma (OAG) or ocular hypertension (OHT) is considered experimental/investigational and not medically necessary.
Coding
| No codes listed |
Provider Actions and Requirements
Prior Authorization Required
Prior authorization is required. A baseline central corneal endothelial cell density measurement must be obtained prior to the initial implant and documented for review. Requests without required baseline data may be denied.
- Authorization type: Prior authorization required for initial and continuation requests
- Baseline central corneal endothelial cell density measurement (e.g., specular or confocal microscopy) required before initial administration
- Continuation: documentation of re-checked corneal endothelial cell density and clinical benefit
Step Therapy
There are no step therapy requirements specified for this policy.
Required Documentation
Submit chart notes and medical records that demonstrate diagnosis, baseline testing, and treatment response. For continuation requests include documentation of ongoing benefit and repeat corneal endothelial cell density measurements.
- Clinical diagnosis supporting use: Open-Angle Glaucoma (OAG) or Ocular Hypertension (OHT)
- Baseline central corneal endothelial cell density measurement method and value (specular or confocal microscopy)
- For continuation: documentation of clinical benefit (chart notes) and repeat endothelial cell density with comparison to baseline (showing <10% loss after adjustments)
- If no baseline in implanted eye: documentation of contralateral eye endothelial cell density and inter-eye difference <10%
- Date of prior iDose TR administration and confirmation the implant is not dislocated
Triggers for Denial
Requests should be denied when the patient does not meet diagnostic or safety criteria, or when exclusions are present.
- Diagnosis is not Open-Angle Glaucoma (OAG) or Ocular Hypertension (OHT)
- Baseline corneal endothelial cell density not obtained and neither baseline nor acceptable contralateral eye documentation provided
- Corneal endothelial dystrophy present
- Ocular or periocular infection
- Prior corneal transplantation
- Hypersensitivity to Travoprost
- For continuation: evidence of ≥10% loss of corneal endothelial cells compared to baseline after adjustments, or lack of documented clinical benefit
Background
iDose TR is a travoprost intracameral implant indicated to reduce intraocular pressure in patients with open-angle glaucoma (OAG) or ocular hypertension (OHT). The implant delivers travoprost directly into the anterior chamber to lower IOP; monitoring of central corneal endothelial cell density is required per the policy when considering initial placement and any re-administration.
Definitions
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