H04.039 — Chronic enlargement of unspecified lacrimal gland
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Monitoring and follow-up documentation: "Monitor the patient for elevated intraocular pressure and endophthalmitis." and "The labeling advises patients to have follow-up eye examinations at appropriate intervals following treatment with Iluvien."
- When used off-label (case reports/series): clinical records documenting prior treatments tried and failed or were not tolerated (e.g., prior anti-VEGF or steroid injections, systemic corticosteroids or immunosuppressives), objective measures such as visual acuity (ETDRS or Snellen), central foveal thickness / central subfield thickness on OCT, intraocular pressure measurements, and documentation of rationale for implant use.
- Retisert procedural documentation: documentation of surgical insertion into posterior segment and implant lifetime (approx 30 months) and any subsequent replacement if recurrence after depletion.
Key Coverage Criteria
- Retisert (fluocinolone acetonide intravitreal 0.59 mg implant) and Yutiq (fluocinolone acetonide intravitreal 0.18 mg implant) for the treatment of chronic non-infectious uveitis (including birdshot chorioretinopathy) affecting the posterior segment of the eye in persons who do not respond to or are intolerant to conventional treatment (i.e., failed corticosteroid or immunosuppressive therapy);
- Iluvien (fluocinolone acetonide intravitreal implant) for the treatment of diabetic macular edema in persons who have been previously treated with a course of corticosteroids and did not have a clinically significant rise in intraocular pressure.
- Retisert: FDA approved ... for the treatment of chronic non-infectious uveitis affecting the posterior segment of the eye.
- On October 16, 2018, the FDA approved Yutiq, an intravitreal 0.18 mg fluocinolone acetonide implant for patients with chronic noninfectious posterior uveitis.
- For the treatment of diabetic macular edema: Iluvien (0.19 mg fluocinolone acetonide): Inject 1 implant (containing 0.19 mg fluocinolone acetonide) intravitreally.
- Iluvien (fluocinolone acetonide intravitreal implant) 0.19 mg is a sustained release intravitreal implant approved by the FDA to treat DME in patients who have been previously treated with a course of corticosteroids and did not have a clinically significant rise in intraocular pressure (Alimera Sciences, 2014).
1 Active Policy
AETNA-CPB-0719 — Fluocinolone Acetonide Intra-vitreal Implant (Retisert, Yutiq and Iluvien)
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