CurrentCignaPolicy IP0738

Qlosi

This Cigna policy governs coverage determinations for Qlosi (pilocarpine HCL ophthalmic solution) when used to treat presbyopia in adults under benefit plans administered by Cigna Companies.

Policy Summary

PayerCigna

PolicyQlosi

Policy CodePolicy IP0738

Change TypeNew policy

Effective DateJun 1, 2025

Next Review DateN/A

Key ActionDo not submit claims for Qlosi for presbyopia as covered; follow the applicable benefit plan and use appropriate diagnosis and procedure codes when billing.

SourceLink

POLICY UPDATE CHANGES

New policy stating Qlosi for the treatment of presbyopia in adults is considered not medically necessary.

Not medically necessaryCoverage stance

FDA approvedRegulatory status

Adults 42-55yPopulation

06/01/2025Effective

Coverage Determinations

Not Medically Necessary — Qlosi for Presbyopia

Qlosi for presbyopia: Qlosi (pilocarpine HCL ophthalmic solution) for the treatment of presbyopia in adults is considered to be not medically necessary.

Criteria will be updated as new published data are available.

Qlosi (pilocarpine HCL ophthalmic solution) for the treatment of presbyopia in adults is not medically necessary. Although Qlosi is FDA-approved for presbyopia, this policy states that only treatments required to diagnose or treat an illness, injury, disease or its symptoms are considered medically necessary; Qlosi for presbyopia does not meet that standard under this policy. Criteria will be updated as new published data are available.

Qlosi (pilocarpine HCL ophthalmic solution) for the treatment of presbyopia in adults is considered to be not medically necessary.

Coding

Covered CPT Codesmixed

No codes listed

Provider Actions & Billing

Policy Summary

PayerCigna

PolicyQlosi

Policy CodePolicy IP0738

Change TypeNew policy

Effective DateJun 1, 2025

Next Review DateN/A

Key ActionDo not submit claims for Qlosi for presbyopia as covered; follow the applicable benefit plan and use appropriate diagnosis and procedure codes when billing.

SourceLink

On This Page

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Prior Authorization

Prior authorization and coverage determination note

Providers must submit prior authorization and coverage requests in accordance with Cigna procedures. When billing, use the most appropriate and current diagnosis and procedure codes as of the date of submission.

Prior authorization may be required by the member's plan — check benefit documents and Cigna requirements before rendering services.

Note

Billing Rule

Coding and billing requirement

When submitting claims, providers must bill using the most appropriate codes current at time of submission. Claims submitted with codes that are not covered under this policy will be denied as not covered.

Billing must use the most appropriate codes as of the effective date of submission.
Claims for services billed without covered diagnosis or procedure codes under the applicable Coverage Policy will be denied as not covered.

Denial Risk

Denial for non-covered coding

Claims submitted for services that are not accompanied by covered code(s) under the applicable Coverage Policy will be denied as not covered.

Denial applies when providers bill for conditions or diagnoses not covered under this Coverage Policy.
Ensure codes submitted match covered indications and the member's benefit plan; in case of conflict, the benefit plan document controls.

Definitions

Presbyopia — definition and clinical note

DefinitionPresbyopia: the irreversible loss of the eye's accommodative ability due to aging, causing progressive near-vision impairment.

Typical age of symptom onsetFirst symptoms commonly reported between ages 42 and 44.

Completion of loss of accommodationComplete loss typically occurs between ages 50 and 55.

Common symptomsGradual blurred near vision, squinting, eye strain headaches, increased light requirement, and need to work from greater distances.

Pathophysiology noteBelieved to result from gradual thickening and loss of flexibility of the natural lens (age-related), distinct from refractive errors like myopia or astigmatism.

Qlosi — drug definition and mechanism/indication

Generic and formulationQlosi (pilocarpine HCL ophthalmic solution).

Mechanism of actionCholinergic muscarinic receptor agonist.

IndicationIndicated for the treatment of presbyopia in adults.

Regulatory status (from brief)FDA approved for presbyopia (see policy summary).

OpenPayer

Qlosi

Coverage Determinations

Coding

Provider Actions & Billing

Background

Definitions