J1096, Dexamethasone, lacrimal ophthalmic insert, 0.1 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Authorization for Dextenza must be no more than 60 days.
- Individuals should be informed of potential adverse events (including cataracts, increased intraocular pressure, hypotony, endophthalmitis, and risk for additional surgical procedures) and should make an informed choice among treatment options.
- Coverage determinations require review of the member's benefit contract or Summary Plan Description (SPD) for defined coverage, exclusions, and limitations (e.g., dollar or duration caps).
Key Coverage Criteria
- An intravitreal and punctum corticosteroid implant may be considered medically necessary when used as an alternative in individuals intolerant or refractory to other therapies, or in individuals likely to experience severe adverse events from systemic corticosteroids, per FDA-approved indications.
- Medically necessary intravitreal and punctum corticosteroid implants when used as an alternative for those intolerant/refractory to other therapies or in individuals likely to experience severe adverse events from systemic corticosteroids.
- Intravitreal implant per FDA-approved indications may be covered as an alternative for individuals intolerant or refractory to other therapies, or judged likely to experience severe adverse events from systemic corticosteroids.
- Medically necessary: Retisert 0.59 mg intravitreal fluocinolone acetonide implant for chronic noninfectious uveitis affecting the posterior segment of the eye in individuals aged 12 years and older.
7 Active Policies
UHC-POL-intravitreal-corticosteroid-implants, Intracanalicular and Intravitreal Corticosteroid Implants
BCBSIL-OTH903.024, Intravitreal, Punctum, and Intracameral Implants
BCBSMT-OTH903.024, Intravitreal, Punctum, and Intracameral Implants
BCBSNM-OTH903.024, Intravitreal, Punctum, and Intracameral Implants
BCBSOK-OTH903.024, Intravitreal, Punctum, and Intracameral Implants
Related Codes
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