CurrentCignaPolicy IP0721

Lacrisert (hydroxypropyl cellulose ophthalmic insert) for dry eye disease — Coverage and prior authorization

Defines Cigna's coverage and prior authorization requirements for Lacrisert for members under health benefit plans administered by Cigna Companies, applicable to treatment of moderate to severe dry eye conditions.

Policy Summary

PayerCigna

PolicyLacrisert (hydroxypropyl cellulose ophthalmic insert) for dry eye disease

Policy CodePolicy IP0721

Change TypeMaterial changes to prior authorization and conditions not covered

Effective Date

Next Review Date

Key ActionObtain prior authorization and document an adequate trial of artificial tears before requesting Lacrisert; approvals are granted for 1 year when criteria are met.

SourceLink

POLICY UPDATE CHANGES

Prior Authorization is required for benefit coverage of Lacrisert and approvals are provided for specified durations.

Approved use limited to ocular conditions associated with moderate to severe dry eye when the patient has tried artificial tears; approval for 1 year.

Conditions Not Covered statement was updated.

1 yearstandard approval duration for Lacrisert when criteria met

Prior Authorizationrequired for Lacrisert coverage

moderate to severedisease severity indication for Lacrisert

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Coverage Criteria for Lacrisert

Medically necessary use

Covered when ALL of the following are met:

Initial approval criteria: Patient has an ocular condition associated with moderate to severe dry eye (examples: decreased corneal sensitivity, dry eye syndrome, exposure keratitis, keratoconjunctivitis sicca, recurrent corneal erosions) AND the patient has tried artificial tears.N/A

Approve for 1 year when criteria met.

Use of Lacrisert for any indication other than those specified in this policy is considered not medically necessary. The policy’s coverage criteria will be updated as new published data become available.

Lacrisert for any use other than ocular conditions associated with moderate to severe dry eye (as specified elsewhere in this policy) is considered not medically necessary.

Coding Expectations

Coding expectations (no explicit codes listed)mixed

affected codes

Policy indicates claims must be submitted with the most appropriate diagnosis and procedure codes; specific codes not listed in document.

Provider Actions and Requirements

Prior Authorization

Prior authorization required

Prior authorization is required for benefit coverage of Lacrisert. Approvals are provided for 1 year when the coverage criteria are met.

Step Therapy

Step therapy requirement: try artificial tears first

An adequate trial of artificial tear solutions is required before Lacrisert will be approved; Lacrisert is indicated especially for patients who remain symptomatic after such a trial.

Documentation Required

Required documentation and coding

Submit claims using the most appropriate diagnosis and procedure codes and include an approved prior authorization; follow the applicable benefit plan document and this coverage policy when billing.

Background on Lacrisert

Lacrisert is a slow‑release hydroxypropyl cellulose ophthalmic insert indicated for moderate to severe dry eye syndromes, including keratoconjunctivitis sicca. It is intended for patients who remain symptomatic despite an adequate trial of artificial tears and may be considered for related conditions such as decreased corneal sensitivity, exposure keratitis, and recurrent corneal erosions.

Definitions

inv-10: Dry eye disease (keratoconjunctivitis sicca) — disease classification and management notes

Disease nameDry eye disease (keratoconjunctivitis sicca)

Severity classificationClassified by symptoms and signs as mild, moderate, or severe with emphasis on symptoms

Primary management emphasisSymptom control with artificial tears as a mainstay of therapy

Role of LacrisertSlow‑release hydroxypropyl cellulose ophthalmic insert indicated for moderate to severe dry eye, especially after an adequate trial of artificial tears

Additional indications for LacrisertConsidered for exposure keratitis, decreased corneal sensitivity, and recurrent corneal erosions