CurrentBlue Cross Blue Shield - TennesseePolicy N/A

iDose TR (travoprost intracameral implant) — Coverage Criteria and Prior Authorization

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.

Policy Summary

PayerBlue Cross Blue Shield - Tennessee

PolicyiDose TR (travoprost intracameral implant) — Coverage Criteria and Prior Authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 31, 202650d

Next Review DateN/A

Key ActionObtain prior authorization with baseline central corneal endothelial cell density documented before initial implant.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsauthorization duration for continuation

10%max endothelial cell loss for continuation

8 tiersendothelial density thresholds

OAG/OHTFDA-approved indication

Coverage Criteria

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.

Initial Therapy

Covered when ALL of the following are met

Initial Coverage Criteria: Baseline measurement of central corneal endothelial cell density obtained prior to initial implant AND medication used for reduction of intraocular pressure (IOP) with diagnosis of Open-Angle Glaucoma (OAG) or Ocular Hypertension (OHT)see Appendix A for density thresholds

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

Continuation Criteria: Member is benefitting and continues to require intraocular pressure (IOP) reduction; has diagnosis of Open-Angle Glaucoma (OAG) or Ocular Hypertension (OHT); more than 12 months have passed since last iDose TR in the affected eye; previous iDose TR implant is not dislocated; corneal endothelial cell density re-checked and affected eye has not lost >=10% of cells compared to baseline after adjusting for normal age-related loss and prior cataract surgery if applicable<10% loss vs baseline after adjustments

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.

Provider Actions and Requirements

Prior Authorization

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.

Documentation Required

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

Denial Risk

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

OpenPayer

iDose TR (travoprost intracameral implant) — Coverage Criteria and Prior Authorization

Coverage Criteria

Coding

Provider Actions and Requirements

Background

Definitions