Prior authorization required; 60‑day authorization and one per‑eye limit

Prior authorization is required and authorizations are limited to no more than 60 days; dose must not exceed one insert/implant per eye as specified by product criteria.

• Prior authorization required with documentation that product‑specific coverage criteria are met.
• Authorization period limited to no more than 60 days.
• Dose limited to one insert/implant per eye.

Iluvien requires prior corticosteroid exposure without significant IOP rise

For Iluvien, prior clinical history must document a course of corticosteroid treatment and that the member did not have a clinically significant rise in intraocular pressure.

• Member previously treated with a course of corticosteroids.
• No clinically significant rise in intraocular pressure during that corticosteroid course.

Updated applicable codes — J7314 removed; verify current codes and benefits

The policy removes HCPCS code J7314 from the Applicable Codes list; providers must follow current applicable code sets and verify benefit plan requirements for prior authorization and billing.

• HCPCS code J7314 was removed from Applicable Codes.
• Use current HCPCS/J code sets when submitting claims and checking prior authorization needs.
• Verify benefit plan contractual, state or federal requirements that may affect coding and authorization.

Document prior corticosteroid trial and IOP response for Iluvien

When requesting coverage for Iluvien, include documentation of the prior corticosteroid course and clinical response (specifically no clinically significant increase in IOP) to satisfy the product‑specific prior steroid trial requirement.

• Document the corticosteroid regimen used (agent, route, dates).
• Document clinical monitoring showing no clinically significant intraocular pressure increase during/after the steroid course.

Step‑wise prior therapy for DME — document prior macula‑directed treatments

For diabetic macular edema, implants (Iluvien, Ozurdex) are considered in patients with persistent DME despite prior macula‑directed therapy; prior macular laser or other prior therapy should be documented as part of step‑therapy context.

• Document prior macular laser or other prior therapy and persistent DME despite those treatments.
• Recognize implants are positioned for persistent disease after prior macula‑directed interventions.

Provider instructions and governing benefit guidance (administrative)

See Instructions for Use section for governing benefit plan statements and other administrative instructions provided in the policy.

• The policy instructs providers to reference federal, state, or contractual benefit plan requirements that govern coverage.
• UnitedHealthcare may use third‑party tools (e.g., InterQual) to assist in administering benefits.

Document diagnosis that matches product‑specific criteria

Document the diagnosis consistent with the product‑specific criteria (e.g., postoperative ocular inflammation/pain or allergic conjunctivitis for Dextenza; chronic non‑infectious posterior uveitis or specified DME criteria for Iluvien; BRVO/CRVO macular edema, posterior non‑infectious uveitis, or DME for Ozurdex; chronic non‑infectious posterior uveitis for Retisert).

• Ensure the submitted diagnosis matches the specific product indication listed in the policy.
• Include laterality and relevant diagnostic details (e.g., DME, BRVO/CRVO, posterior non‑infectious uveitis).

Support implant choice, prior treatments, outcomes, and monitoring in clinical records

Include clinical documentation supporting the chosen implant and indication, prior treatments and responses, and monitoring for adverse events (e.g., intraocular pressure elevations, cataract formation). For Iluvien specifically, include documentation of prior corticosteroid treatment and IOP monitoring results.

• Support implant choice with indication‑specific clinical notes and prior treatment history.
• Document monitoring and outcomes, including IOP measurements and any interventions for elevated IOP or cataract.

Reference governing federal, state, or contractual benefit documents

Reference federal, state, or contractual benefit plan requirements when submitting authorization or claims, as those requirements govern in the event of a conflict with this policy.

• If federal, state, or contractual terms differ from this policy, those terms take precedence.
• Verify applicable plan documents before relying solely on this policy for coverage decisions.

Non‑listed indications are not medically necessary — risk of denial

Use of intracanalicular and intravitreal corticosteroid implant products for any indication not listed (for example, cystoid macular edema after cataract surgery or radiation retinopathy) is considered not medically necessary and may be denied.

• Do not submit authorization requests for indications outside the policy’s listed indications; such requests may be denied as not medically necessary.
• Examples of non‑covered indications include cystoid macular edema after cataract surgery and radiation retinopathy.

Iluvien approval requires documented prior steroid course without clinically significant IOP rise

Iluvien may be approved only for patients who have been previously treated with a course of corticosteroids and who did not experience a clinically significant rise in intraocular pressure; lack of documentation of prior steroid exposure and IOP response could result in denial.

• Document the prior corticosteroid course and contemporaneous IOP assessments showing no clinically significant rise.
• Authorization for Iluvien for DME requires this documented prior steroid history.

Coding or contractual conflicts (e.g., removed J7314) can trigger denials

Failure to follow updated Applicable Codes (HCPCS code J7314 removed) or to reference applicable federal, state, or contractual benefit requirements when they conflict with this policy may trigger denial or claim coverage issues.

• Do not bill or authorize using HCPCS code J7314; use the current codes listed in the policy and submit claims consistent with plan requirements.
• If plan contracts or state/federal rules differ, those governing rules apply and may affect coverage decisions.