J7313, Injection, fluocinolone acetonide, intravitreal implant (iluvien), 0.01 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
- Submit HCPCS code J7313 (fluocinolone acetonide intravitreal implant, 0.19 mg) on Part B claims.
- Include total dosage '0.19 mg' in the narrative field of the claim.
- Include an appropriate ICD-10 diagnosis code for DME on the claim (policy references 'one of the ICD-10 diagnoses below').
- Maintain medical record documentation showing prior course of corticosteroid treatment for DME and documentation of IOP response (e.g., ophthalmology notes and IOP measurements).
Key Coverage Criteria
- Treatment of diabetic macular edema (DME).
- Patient has previously received a course of corticosteroid therapy for DME.
- No clinically significant rise in intraocular pressure (IOP) occurred during prior corticosteroid treatment.
- 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.
9 Active Policies
A54750, Billing and Coding: FDA approves Iluvien for Diabetic Macular Edema
UHC-POL-intravitreal-corticosteroid-implants, Intracanalicular and Intravitreal Corticosteroid Implants
AETNA-CPB-0719, Fluocinolone Acetonide Intra-vitreal Implant (Retisert, Yutiq and Iluvien)
BCBSIL-OTH903.024, Intravitreal, Punctum, and Intracameral Implants
BCBSMT-OTH903.024, Intravitreal, Punctum, and Intracameral Implants
Related Codes
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