CurrentCignaPolicy IP0088

Upneeq (oxymetazoline 0.1% ophthalmic solution) coverage

Defines Cigna's coverage stance for Upneeq for treatment of acquired blepharoptosis and other uses; describes conditions considered not medically necessary or experimental and applies to health benefit plans administered by Cigna Companies.

Policy Summary

PayerCigna

PolicyUpneeq (oxymetazoline 0.1% ophthalmic solution) coverage

Policy CodePolicy IP0088

Change TypeMaterial clinical and wording updatesadded experimental/unproven and cosmetic-use NMN statements

Effective DateMar 15, 2025

Next Review DateN/A

Key ActionFollow the member's benefit plan and utilization review processes for any prior authorization requirements.

SourceLink

POLICY UPDATE CHANGES

Oxymetazoline hydrochloride 0.1% ophthalmic solution (Upneeq) is considered to be experimental, investigational, or unproven for blepharoptosis or conjunctivitis due to insufficient data establishing safety, efficacy, and improved health outcomes for any condition, regardless of U.S. Food and Drug Administration (FDA) approval status.

Language regarding cosmetic use exclusion was updated to state Upneeq for cosmetic uses (i.e., blepharoptosis when functional limitation is absent) is considered not medically necessary.

Removal of prior broad statement 'Any other use is considered experimental, investigational, or unproven, including the following (this list may not be all inclusive):'

FDA indicatedIndication

2 (n=304)Phase 3 trials

6 weeks

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.

Not addressedGuidelines

Coverage Determination and Criteria

Coverage determination

Coverage stance and criteria:

Overall stance: Despite an FDA label indication for acquired blepharoptosis in adults, Cigna considers oxymetazoline hydrochloride 0.1% ophthalmic solution (Upneeq) to be experimental, investigational, or unproven for blepharoptosis or conjunctivitis due to insufficient data establishing safety, efficacy, and improved health outcomes; Upneeq for cosmetic blepharoptosis (i.e., when functional limitation is absent) is considered not medically necessary.

Policy references two Phase 3 randomized, double-masked, placebo-controlled studies (n=304) with primary and secondary endpoints assessed up to 6 weeks and notes small numerical improvements and lack of long-term efficacy data; role in management not established.

Oxymetazoline hydrochloride 0.1% ophthalmic solution (Upneeq) for cosmetic uses — specifically blepharoptosis when functional limitation is absent — is considered not medically necessary and is excluded from coverage.

Upneeq is considered experimental, investigational, or unproven for the treatment of blepharoptosis or conjunctivitis due to insufficient data establishing safety, efficacy, and improved health outcomes. This policy notes the limited clinical evidence (two Phase 3 trials, short duration) and states that criteria will be updated as new published data become available.

Product Reference and Codes

Product referenceNDC

NDC not listed

Upneeq (oxymetazoline hydrochloride 0.1% ophthalmic solution) product reference; specific NDCs not provided in policy

Provider Requirements and Operational Notes

Prior Authorization

Prior Authorization Required

Prior authorization is required per plan terms. Verify member eligibility and benefit coverage prior to initiating therapy. Coverage determinations must follow the member's specific plan document and applicable laws/regulations.

Prior authorization required per plan terms
Confirm plan benefits and exclusions in the member's Evidence of Coverage or Summary Plan Description
Medical director review required for cases outside standard criteria

Documentation Required

Provider Submission Requirements

Submit clinical documentation that supports medical necessity. Include documentation of functional limitation from blepharoptosis (e.g., visual field testing, MRD1 measurements, photographs) when applicable. For requests where Upneeq is being prescribed for cosmetic purposes (blepharoptosis without functional limitation), expect denial as not medically necessary.

Clinical Background

Blepharoptosis (ptosis) is an abnormal drooping of one or both upper eyelids and may be congenital or acquired; acquired ptosis is common in older adults and often aponeurotic in origin. Upneeq (an alpha-adrenergic agonist) has an FDA indication for acquired blepharoptosis in adults, but published Phase 3 studies (n = 304) were of short duration (42 days) and showed only small numeric improvements in superior visual field (Leicester Peripheral Field test) and in MRD1 compared with vehicle. The clinical meaningfulness and long-term role of Upneeq in managing blepharoptosis remain unestablished.

Key Definitions and Measures

Blepharoptosis (ptosis) — definition and etiologies

DefinitionAbnormal drooping of one or both upper eyelids (blepharoptosis, ptosis).

Onset typesCan be congenital or acquired; acquired ptosis is most commonly seen in older adults.

Common acquired etiologyAponeurotic (involutional) ptosis due to stretching, dehiscence, or disinsertion of the levator aponeurosis.

Less frequent etiologiesMyogenic (e.g., myasthenia gravis), neurogenic (e.g., third nerve palsy), traumatic (e.g., eyelid laceration), or mechanical (e.g., eyelid mass or cicatricial changes).

Clinical impact and managementCan cause significant psychosocial effects; surgical interventions are the primary management to improve visual field or cosmesis but carry risks (bleeding, infection, under/overcorrection, asymmetry, granuloma, corneal issues) and recurrence may occur.

Policy Summary

PayerCigna

PolicyUpneeq (oxymetazoline 0.1% ophthalmic solution) coverage

Policy CodePolicy IP0088

Change TypeMaterial clinical and wording updatesadded experimental/unproven and cosmetic-use NMN statements

Effective DateMar 15, 2025

Next Review DateN/A

Key ActionFollow the member's benefit plan and utilization review processes for any prior authorization requirements.

SourceLink

On This Page

Include objective evidence of functional impairment (e.g., superior visual field deficit documented by Leicester Peripheral Field Test or equivalent)

Provide MRD1 measurements and clinical notes describing functional impact

Attach prior-treatment history and rationale if considering non-surgical management

Denial Risk

Denial and Claims Guidance

When Upneeq is requested for blepharoptosis without documented functional limitation, deny as not medically necessary. Reference the plan document and policy language when communicating the denial. If clinical information suggests experimental or investigational use (e.g., conjunctivitis or other non‑established indications), deny as experimental/unproven.

Denial reason: Not medically necessary — cosmetic use (blepharoptosis without functional limitation)
Denial reason: Experimental/investigational — insufficient evidence for conjunctivitis or other non‑established indications
Reference applicable plan document language and provide appeal instructions per member's plan

Billing Rule

Claims and Billing — Cosmetic Use (Blepharoptosis without Functional Limitation)

For cosmetic use claims (Upneeq for blepharoptosis without functional limitation), do not authorize and code/submit claims accordingly. Ensure billing reflects non-covered status when denial issued to prevent improper payment. If a member appeals, supply complete clinical records including objective testing and rationale for medical necessity.

Affected codes: report applicable HCPCS/CPT/NDC codes per billing guidance (verify current code set)
If denied, bill as non-covered service per plan instructions and include denial code on claim
Provide complete documentation on appeal: visual field test results, MRD1 measures, clinical photographs, and treating physician rationale

MRD1 (marginal reflex distance 1) — definition and measurement note

DefinitionMarginal reflex distance 1 (MRD1) is the distance between the center of the pupillary light reflex and the upper eyelid margin with the eye in primary gaze.

Measurement contextMeasured with the eye in primary gaze; used as a secondary endpoint in clinical trials of Upneeq (assessed on Days 1 and 14).

Clinical trial findingsPhase 3 studies showed statistically significant but numerically small changes in MRD1 with Upneeq versus vehicle; clinical meaningfulness of these changes is unclear.