Coverage Policies

Use the index below to search for coverage information on specific medical conditions.

Note: For Arkansas State or Public School employees, services subject to pre-authorization are managed by Active Health Management, as noted in their Summary Plan Description.

For coverage information on high tech imaging (MRI, CT, PET) and nuclear medicine, administered by Evicore, click here.

Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

If not specified in a QualChoice coverage policy (Benefit Interpretation), QualChoice follows care guidelines published by MCG Health.

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 01/01/2007 Title: Corticosteroid Intravitreal Implants (Ozurdex, Retisert, Iluvien)
Revision Date: 04/01/2019 Document: BI204:00
CPT Code(s): J7311
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Corticosteroid Intravitreal Implants (Ozurdex, Retisert, and Iluvien) require prior authorization.

2)    Retisert is a plastic device which is implanted into the eye for the treatment of non-infectious uveitis affecting the posterior segment of the eye..

3)    Iluvien is indicated for the treatment of diabetic macular edema I patients who have been previously treated with corticosteroids and did not have a clinically significant rise in intraocular pressure.

4)    Ozurdex is indicated for the treatment of a) macular edema following brand retinal vein occlusion (BRVO) or central retinal vein occlusion (CRVO), b) non-infectious uveitis affecting the posterior segment of the eye, and c) diabetic macula edema (DME).


Medical Statement

1)    Corticosteroid intravitreal implants (Retisert,Iluvien, and Ozurdex) all require prior authorization.

2)    Retisert is considered medically necessary for members meeting the following criteria:

a)    Member is 12 years of age or older AND

b)    Diagnosis of non-infectious uveitis affecting the posterior segment of the eye AND

c)    Prescribed by or in consultation with an ophthalmologist AND

d)    Failure of all of the following unless contraindicated or clinically significant adverse effects are experienced:

i)     Intravitreal steroid injections;

ii)    Systemic corticosteroid;

iii)   Non-biologic immunosuppressive therapy;

e)    Dose does not exceed one (1) implant per eye

3)    Iluvien is considered medically necessary for members meeting the following criteria:

a)    Member is 18 years of age older AND

b)    Diagnosis of Diabetic Macular Edema (DME) AND

c)    Prescribed by or in consultation with an ophthalmologist AND

d)    Failure of both of the following:

i)     Intravitreal steroid injection;

ii)    Intravitreal anti-VEGF agents;

     e) Dose does not exceed one (1) implant per eye.

4) Ozurdex is considered medically necessary for members meeting the following criteria:

Diabetic Macular Edema

a)    Member is 18 years of age or older AND

b)    Diagnosis of diabetic macular edema (DME) AND

c)    Prescribed by or in consultation with an ophthalmologist AND

d)    Failure of both of the following unless contraindicated or clinically significant adverse effects are experienced:

i)     Intravitreal steroid injections;

ii)    Intravitreal ant-VEGF agents

e)    Dose does not exceed one (1) implant per eye

 

Macular Edema following branch retinal vein occlusion (BRVO) or central retinal vein occlusion (CRVO)

a)    Member is 18 years of age or older AND

b)    Diagnosis of macular edema following BRVO or CRVO AND

c)    Prescribed by or in consultation with an ophthalmologist AND

d)    Failure of both of the following unless contraindicated or clinically significant adverse effects are experienced:

1)    Intravitreal steroid injections;

2)    Intravigtreal antiVEGF agents;

e)    Dose does not exceed one (1) implant per eye.

 

 

Codes Used In This BI:

J7311             Fluocinolone acetonide intravitreal implant

J7312             Injection, dexamethasone, intravitreal implant, 0.1mg

J7313             Injection, fluocinolone acetonide intravitreal implant, 0.01mg


Reference

1)    Iluvien Prescribing Information. Alpharetta, GA: Alimiera Sciences, Inc. Novembe 2016.

2)    Ozurdex Prescribing Information. Irvine, CA: Allergan, Inc. September 2014.

3)    Retisert Prescribing Information. Bridgewater, NJ: Valeant Pharmaceuticals; December 2017.


Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.