Intracanalicular and Intravitreal Corticosteroid Implants

Coverage Summary

Scope: This UnitedHealthcare Community Plan medical benefit drug policy (Policy No. CS2026D00107J) governs coverage criteria, indications, and applicable procedure/diagnosis codes for intracanalicular and intravitreal corticosteroid implant products (Dextenza, Iluvien, Ozurdex, Retisert, Yutiq).

Coverage stance: Covered with criteria — implants are medically necessary for specified ophthalmologic indications when the policy’s product-specific criteria are met (see product sections).

Policy subject and dates: Subject = Intracanalicular and Intravitreal Corticosteroid Implants; Effective date = April 1, 2026; Last review = April 1, 2026.

State applicability / changes: The policy applies to most states but the Application section lists state-specific references; recent changes removed prior non-applicability language for Indiana and removed Louisiana-specific content and archived the prior version (see Summary of Changes dated 04/01/2026).

Initial Therapy / Medically Necessary Criteria

Dextenza - Medically Necessary Criteria

Dextenza is proven and medically necessary when ALL of the following criteria are met:

ALL of the following

One of the following diagnoses
- Ocular inflammation and pain following ophthalmic surgery
- Ocular itching associated with allergic conjunctivitis
ALL of the following
- Prescribed by or in consultation with an ophthalmologist
- Dose does not exceed one insert per eyedose does not exceed one insert per eye
  Maximum one insert per eye
- Authorization is for no more than 60 daysno more than 60 days
  Authorization duration limit

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Not Medically Necessary / Unproven Indications

Applicable Codes

J-codes (drug/procedure)HCPCS

J1096	Dexamethasone, lacrimal ophthalmic insert, 0.1 mg
J7311	Injection, fluocinolone acetonide, intravitreal implant (Retisert), 0.01 mg
J7312	Injection, dexamethasone, intravitreal implant, 0.1 mg
J7313	Injection, fluocinolone acetonide, intravitreal implant (Iluvien), 0.01 mg
J7314	Injection, fluocinolone acetonide, intravitreal implant (Yutiq), 0.01 mg

ICD-10 Diagnosis Codes - Diabetic Macular Edema and relatedICD-10

E08.311	Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema
E08.3211	Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, right eye
E08.3212	Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, left eye
E08.3213	Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, bilateral
E08.3219	Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye
E08.3311	Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, right eye
E08.3312	Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, left eye
E08.3313	Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, bilateral
E08.3319	Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye
E08.3411	Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, right eye

1–10 of 97

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ICD-10 Diagnosis Codes - Retinal Vein Occlusion and Macular EdemaICD-10

H34.8110	Central retinal vein occlusion, right eye, with macular edema
H34.8120	Central retinal vein occlusion, left eye, with macular edema
H34.8130	Central retinal vein occlusion, bilateral, with macular edema
H34.8190	Central retinal vein occlusion, unspecified eye, with macular edema
H34.8310	Tributary (branch) retinal vein occlusion, right eye, with macular edema
H34.8320	Tributary (branch) retinal vein occlusion, left eye, with macular edema
H34.8330	Tributary (branch) retinal vein occlusion, bilateral, with macular edema
H34.8390	Tributary (branch) retinal vein occlusion, unspecified eye, with macular edema

ICD-10 Diagnosis Codes - Non-Infectious Uveitis Affecting Posterior SegmentICD-10

H20.041	Secondary noninfectious iridocyclitis, right eye
H20.042	Secondary noninfectious iridocyclitis, left eye
H20.043	Secondary noninfectious iridocyclitis, bilateral
H20.049	Secondary noninfectious iridocyclitis, unspecified eye
H30.001	Unspecified focal chorioretinal inflammation, right eye
H30.002	Unspecified focal chorioretinal inflammation, left eye
H30.003	Unspecified focal chorioretinal inflammation, bilateral
H30.009	Unspecified focal chorioretinal inflammation, unspecified eye
H30.011	Focal chorioretinal inflammation, juxtapapillary, right eye
H30.012	Focal chorioretinal inflammation, juxtapapillary, left eye

1–10 of 58

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ICD-10 Diagnosis Codes - Ocular Pain/Inflammation & Allergic ConjunctivitisICD-10

H57.10	Ocular pain, unspecified eye
H57.11	Ocular pain, right eye
H57.12	Ocular pain, left eye
H57.13	Ocular pain, bilateral
H10.45	Other chronic allergic conjunctivitis

Provider Actions & Prior Authorization

Prior Authorization

Authorization required with duration limit

Authorization must be obtained and is limited to no more than 60 days for each implant/insert; ensure the request documents the indication and that dose does not exceed one insert/implant per eye.

J1096
J7311
J7312
J7313
J7314
ensure request documents indication and dose limit

Documentation Required

Specialist involvement required

Prescriptions must be by or in consultation with an ophthalmologist; document the consultation or prescribing ophthalmologist in the medical record.

Clinical Evidence Summary

28.7% ≥15-letter BCVA at 24 months (FA low-dose)

28.6% ≥15-letter BCVA at 24 months (FA high-dose)

22.2% ≥15-letter BCVA (DEX 0.7 mg) in DME

16Peak % IOP ≥25 mmHg (DEX RVO, day 60)

Campochiaro et al. (FA inserts for DME): both low- and high-dose fluocinolone acetonide inserts improved BCVA at 24 months vs sham (28.7% and 28.6% vs 16.2% achieving ≥15-letter improvement); glaucoma requiring incisional surgery occurred in 3.7% (low) and 7.6% (high) vs 0.5% (sham) (Campochiaro et al.).

Boyer et al. (Ozurdex in DME): DEX 0.7 mg achieved 22.2% with ≥15-letter BCVA improvement vs 12% sham; cataract-related adverse event rates in phakic eyes were 67.9% (0.7 mg), 64.1% (0.35 mg), and 20.4% (sham) (Boyer et al. 2014).

Haller et al. (Ozurdex in RVO): DEX implant reduced time to ≥15-letter improvement vs sham; percentage of eyes with IOP ≥25 mmHg peaked at 16% at day 60 and returned toward sham by day 180 (Haller et al. 2010).

Pavesio et al. (Retisert in NIPU): FA intravitreal implant delayed time to recurrence and reduced recurrence rate vs standard therapy (recurrence 18.2% vs 63.5%); adverse events included 21.2% with elevated IOP requiring surgery and 87.8% cataract extraction in phakic implanted eyes (Pavesio et al.).

Background

Background: Corticosteroid implants deliver sustained intraocular corticosteroid release to treat conditions such as diabetic macular edema (DME), non-infectious posterior uveitis, and macular edema from retinal vein occlusion. Corticosteroids inhibit inflammatory mediators and reduce edema but can also raise intraocular pressure (IOP).

Product differences: Dextenza is a resorbable intracanalicular insert releasing 0.4 mg dexamethasone for up to 30 days and does not require removal; Ozurdex is a biodegradable intravitreal implant containing 0.7 mg dexamethasone designed to release drug for up to 6 months; Iluvien is a non-bioerodible intravitreal implant containing 0.19 mg fluocinolone acetonide releasing ~0.25 µg/day over 36 months; Yutiq is a non-bioerodible intravitreal implant containing 0.18 mg fluocinolone acetonide releasing ~0.25 µg/day over 36 months; Retisert is a non-biodegradable intravitreal implant containing 0.59 mg fluocinolone acetonide with an initial release ~0.6 mcg/day decreasing to ~0.3–0.4 mcg/day over ~30 months.

Key safety concerns and monitoring: Corticosteroid implants are associated with IOP elevation (including cases requiring IOP-lowering surgery) and high rates of cataract/cataract extraction in phakic eyes; these risks require close monitoring of IOP and lens status when implants are used.

DME: Diabetic macular edema (DME).

NIU-PS: Noninfectious uveitis of the posterior segment.

FA: Fluocinolone acetonide.

Authorization duration: No more than 60 days (policy threshold).

Dose limit per eye: Does not exceed one insert/implant per eye.

Revision History

2026-04-01revisedLatest

Summary of changes: removed Indiana non-applicability language; removed Louisiana-specific content; archived previous policy version CS2025D00107I.

2026-04-01removedLatest

Removed language indicating this Medical Benefit Drug Policy does not apply to the state of Indiana.

2026-04-01removed