UnitedHealthcare corticosteroid implant Prior Auth

Coverage Summary

This policy (Policy Number: 2025D0107F; status: CURRENT) defines UnitedHealthcare medical-benefit coverage criteria for intracanalicular (Dextenza) and intravitreal corticosteroid implants (Iluvien, Ozurdex, Retisert, Yutiq) and lists applicable HCPCS/J-codes and ICD-10 diagnosis codes. It applies to commercial and community plan policies; member-specific benefit documents govern final coverage decisions and supersede this policy when differences exist. Authorizations and limits (e.g., number of inserts/implants per eye and duration) are specified in the Coverage Rationale.

Dextenza (dexamethasone intracanalicular insert) - Proven and medically necessary

Covered when ALL of the following are met:

ALL of the following

Indication: ocular inflammation following ophthalmic surgery; or pain; or ocular itching associated with allergic conjunctivitis
Prescribed by or in consultation with an ophthalmologist
Authorization is for no more than 60 daysno more than 60 days
See policy revision (08/01/2025)
Dose does not exceed one insert per eyeone insert per eye

Iluvien (fluocinolone acetonide intravitreal implant) - Proven and medically necessary

Covered when ALL of the following are met:

ALL of the following

Indication: chronic non-infectious uveitis affecting the posterior segment of the eye; or diagnosis of diabetic macular edema (DME)
For DME
- Member has been previously treated with a course of corticosteroids
  Iluvien-specific requirement: prior corticosteroid course required for DME
- Member did not have a clinically significant rise in intraocular pressure
  Iluvien-specific note: absence of clinically significant IOP rise required (policy does not define numeric threshold)
Prescribed by or in consultation with an ophthalmologist

Ozurdex (dexamethasone intravitreal implant) - Proven and medically necessary

Covered when ALL of the following are met:

ALL of the following

Indication: macular edema following branch retinal vein occlusion (BRVO) or central retinal vein occlusion (CRVO); or diabetic macular edema (DME); or non-infectious uveitis affecting the posterior segment of the eye
Prescribed by or in consultation with an ophthalmologist
Authorization is for no more than 60 daysno more than 60 days
See policy revision (08/01/2025)
Dose does not exceed one implant per eyeone implant per eye

Retisert (fluocinolone acetonide intravitreal implant) - Proven and medically necessary

Covered when ALL of the following are met:

ALL of the following

Prescribed by or in consultation with an ophthalmologist
Diagnosis of chronic non-infectious uveitis affecting the posterior segment of the eye
Dose does not exceed one implant per eyeone implant per eye
Authorization is for no more than 60 daysno more than 60 days
See policy revision (08/01/2025)

Yutiq (fluocinolone acetonide intravitreal implant) - Proven and medically necessary

Covered when ALL of the following are met:

ALL of the following

Prescribed by or in consultation with an ophthalmologist
Diagnosis of chronic non-infectious uveitis affecting the posterior segment of the eye
Dose does not exceed one implant per eyeone implant per eye
Authorization is for no more than 60 daysno more than 60 days
See policy revision (08/01/2025)

Unproven / Not medically necessary indications

Products are unproven and not medically necessary for any other indication due to insufficient evidence; including but not limited to:

ANY of the following

Radiation retinopathy
Cystoid macular edema after cataract surgery

Applicable Codes

Drug J-codes (intracanalicular and intravitreal corticosteroid implants)mixed

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: Diabetic Macular Edema (DME) and related diabetes codesICD-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

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ICD-10: Macular Edema Following Retinal Vein OcclusionICD-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: 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

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ICD-10: Ocular inflammation and pain following ophthalmic surgery; itching associated with allergic conjunctivitisICD-10

G89.18	Other acute postprocedural pain
H05.00	Unspecified acute inflammation of orbit
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 (itching associated with allergic conjunctivitis)
H57.14	Ocular pain, unspecified (note: H57.14 not in doc; included if used)

(legacy) — placeholder for any additional implant/product codesmixed

No codes listed

Provider Actions & Authorization

Prior Authorization

Authorization required and duration limit

Authorization is required for intracanalicular and intravitreal corticosteroid implants/inserts and, per the policy revision effective 2025-08-01, authorizations are limited to no more than 60 days.

Affected codes: J1096, J7311, J7312, J7313, J7314
Effective date: 2025-08-01

Documentation Required

Specialist involvement required

Prescriptions for covered indications must be written by or in consultation with an ophthalmologist.

Prescribing requirement: by or in consultation with an ophthalmologist

Clinical Evidence & Background

Corticosteroids act by inducing phospholipase A2 inhibitory proteins, reducing production of inflammatory mediators (prostaglandins and leukotrienes), thereby inhibiting edema and other inflammatory processes; they can also cause a rise in intraocular pressure. Implants and inserts provide sustained ocular drug delivery: Iluvien (non-bioerodible fluocinolone acetonide implant; releases ~0.25 mcg/day over 36 months), Dextenza (resorbable intracanalicular dexamethasone insert; single insert releases 0.4 mg for up to 30 days), Ozurdex (biodegradable dexamethasone 0.7 mg implant; releases drug for up to 6 months), Yutiq (non-bioerodible fluocinolone acetonide implant; releases ~0.25 mcg/day over 36 months), and Retisert (non-biodegradable fluocinolone acetonide implant; nominal initial rate ~0.6 mcg/day decreasing to ~0.3–0.4 mcg/day over ~30 months). Key safety concerns include intraocular pressure (IOP) elevation and cataract formation, which require monitoring.

28.7%Iluvien: BCVA ≥15-letter at 24 months (low-dose) vs sham 16.2%

28.6%Iluvien: BCVA ≥15-letter at 24 months (high-dose) vs sham 16.2%

22.2%Ozurdex (DEX 0.7 mg): ≥15-letter improvement at 3 years vs sham 12%

18.2%FA implant (Pavesio): recurrence rate vs 63.5% standard care; higher IOP-surgery & cataract rates

Definitions

Definitions:

• Authorization: Prior approval for coverage; limited to no more than 60 days per this policy.

• Clinically significant rise in intraocular pressure: referenced as a requirement (e.g., for Iluvien—member must not have had a clinically significant IOP rise after prior corticosteroid course) but is not numerically defined in this policy.

Revision History

2025-08-01material_revision

Policy effective 2025-08-01: revised authorization guidelines—replaced language 'authorization is for no more than one month' with 'authorization is for no more than 60 days' and applied the 60-day authorization limit across covered products (Dextenza, Iluvien, Ozurdex, Retisert, Yutiq).

2025-08-01material_revision

Iluvien coverage criteria updated to add requirement for chronic non-infectious uveitis affecting the posterior segment of the eye (in addition to DME with prior corticosteroid course without clinically significant IOP rise).

2025-09-01editorial_changeLatest

OpenPayer

Intracanalicular and Intravitreal Corticosteroid Implants

Coverage Summary

Applicable Codes

Provider Actions & Authorization

Clinical Evidence & Background

Definitions

Revision History