CurrentCignaPolicy IP0619

iDose TR (travoprost intracameral implant) coverage policy

Coverage policy for iDose TR (travoprost intracameral implant) for reduction of intraocular pressure in adults with open-angle glaucoma or ocular hypertension; describes medical necessity criteria, coding, and limitations for Cigna-administered health plans.

Policy Summary

PayerCigna

PolicyiDose TR (travoprost intracameral implant) coverage policy

Policy CodePolicy IP0619

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionPrior Authorization is recommended for prescription benefit coverage of iDose TR.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

one-time per eyeapproval limit (implants per treated eye)

2 implantsmaximum implants per patient

>=18minimum patient age for coverage

0660T, J7355primary codes listed

Coverage Criteria for iDose TR

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General requirements: A) Patient is >= 18 years of age; AND B) Patient is not receiving re-treatment of eye(s) previously treated with iDose TR; AND E) The medication is administered by or under the supervision of an ophthalmologist.

Medication trial requirements: C) Patient meets BOTH of the following: i) tried at least two ophthalmic prostaglandins (either as monotherapy or concomitant therapy); AND ii) tried at least two other ophthalmic products (either as monotherapy or concomitant therapy) from two different pharmacologic classes for the treatment of open-angle glaucoma or ocular hypertension.

Prior therapy outcome per medication: D) For each ophthalmic medication tried, the patient meets ONE of the following: i) inadequate efficacy to the previously tried ophthalmic products per prescriber; OR ii) adverse event(s) severe enough to warrant discontinuation of the previously tried ophthalmic products per prescriber.

Dosing/limit: Approve up to one iDose TR implant per treated eye (one-time use per eye); total up to two implants per patient.

Any use of iDose TR outside the specified indications and criteria in this policy is considered experimental, investigational, or unproven. The policy explicitly excludes the following: re‑treatment of previously treated eye(s) — iDose TR is approved as a one‑time use per treated eye and repeat administration to an eye that previously received iDose TR is not approvable; and concurrent use of iDose TR with Durysta (bimatoprost intracameral implant), which is not allowed.

Re‑treatment of an eye that has previously received iDose TR is not approvable; the implant is authorized as a one‑time use per treated eye. Additionally, the simultaneous or concurrent use of iDose TR with Durysta (bimatoprost intracameral implant) is specifically excluded and considered experimental/investigational.

Provider Actions, Authorization, and Billing Guidance

Prior Authorization

Prior authorization recommended

Prior Authorization is recommended for prescription benefit coverage of iDose TR. All approvals are provided for the duration noted; approvals require specialist prescribing (i.e., prescribed by a physician who has consulted with or who specializes in the condition).

Covered HCPCS/CPT codes: 0660T, J7355 (see coding section)

Step Therapy

Medication trials required before iDose TR

Patient must have tried at least two ophthalmic prostaglandins (as monotherapy or concomitant therapy) and at least two other ophthalmic products from two different pharmacologic classes (as monotherapy or concomitant therapy) for the treatment of open‑angle glaucoma or ocular hypertension.

Examples of ophthalmic prostaglandins: bimatoprost 0.03% solution; latanoprost 0.005% solution; travoprost 0.004% solution; others listed in policy.
Examples of other pharmacologic classes: beta‑blockers, alpha‑agonist (brimonidine), carbonic anhydrase inhibitors, rho kinase inhibitor (netarsudil).

Documentation Required

Prescriber and approval duration

Approval requires iDose TR to be prescribed by a physician who has consulted with or who specializes in the condition. When an approval is authorized in months, 1 month is equal to 30 days.

Approvals provided for the duration noted; specialized skills and monitoring required for evaluation and long‑term follow up.

Denial Risk

Coding and claim submission

Claims submitted without covered diagnosis or procedure codes will be denied; reimbursement is not allowed for services billed for conditions or diagnoses that are not covered under this policy. When billing, providers must use the most appropriate codes as of the date of submission.

Use covered procedure/HCPCS codes (0660T, J7355) and appropriate covered diagnosis codes to support payment.
Claims for services not accompanied by covered code(s) under this policy will be denied as not covered.

Background

iDose TR is a travoprost intracameral implant indicated to reduce intraocular pressure in patients with open‑angle glaucoma or ocular hypertension. It is a travoprost‑releasing, non‑biodegradable implant that is implanted intracamerally and anchored at the iridocorneal angle to provide sustained delivery of travoprost. Lowering intraocular pressure reduces the risk of optic nerve damage and glaucoma progression; topical ophthalmic agents from multiple classes are typically used prior to considering an intracameral implant.

Definitions

iDose TR — device definition

Device descriptionTravoprost-releasing, non-biodegradable intracameral implant pre-loaded in a sterile single-dose inserter; each implant contains 75 mcg travoprost.

Route and placementAdministered intracamerally through a small clear corneal incision and anchored at the iridocorneal angle (scleral anchor).

Re-administration policyNot to be re-administered to an eye that previously received iDose TR (re-treatment of the same eye is not approvable).

Indication summaryIndicated to reduce intraocular pressure (IOP) in open‑angle glaucoma or ocular hypertension.

Dosage per implantEach implant contains 75 micrograms (mcg) of travoprost.