Does J7312 require prior authorization?

Yes, J7312 requires prior authorization (medium confidence). Conditional coverage; review criteria to confirm PA need.

What is the Medicare reimbursement rate for J7312?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`J7312`, Injection, dexamethasone, intravitreal implant, 0.1 mg

HCPCS/CPT

Prior Authorization

Prior Auth Required

Conditional coverage; review criteria to confirm PA need (medium 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.
Documentation that other intractable severe migraine attacks were unresponsive to analgesics and triptans (example list of triptans provided in policy).

Key Coverage Criteria

Magnesium supplementation for migraine prevention in adults (limited evidence from small RCTs with mixed results; discussed as a possible option).
IV ketamine infusion combined with magnesium sulfate for chronic intractable cluster headache (case reports showing symptomatic relief; Moisset et al. 2017).
Intravenous and intranasal ketamine for acute/abortive treatment of migraine (multiple small RCTs, open-label studies and systematic reviews/meta-analyses; potential short-term analgesic benefit reported).
Inpatient continuous or multi-day ketamine or lidocaine infusion protocols as therapy for refractory chronic migraine (rCM) when other treatments have failed (practice series and pilot studies; Mojica et al. 2021; Schwenk et al. 2021; Ray et al. 2022).
Transcutaneous supraorbital neurostimulation (tSNS, Cefaly device / extra-cephalic supraorbital TNS) for preventive treatment of episodic migraine (randomized trial evidence suggesting superiority to sham in episodic migraine prevention; Russo & Tessitore 2015; UpToDate summary referencing RCT).
Intramuscular (IM) ketorolac (Toradol) for acute migraine treatment in adults (RCTs comparing IM ketorolac to other agents showing similar efficacy; Duarte et al. 1992; Shrestha et al. 1996; also supported in ED settings per UpToDate).

11 Active Policies

ARKBLUE-INTRAVITREAL-PUNCTUM-CORTICOSTEROID-IMPLANTS-E-G-0FC5C40DCA, Intravitreal, Punctum Corticosteroid Implants (e.g., Retisert, Yutiq, Iluvien, Ozurdex, and Dextenza)

HEALTHNET_OR-HNOR-CORTICOSTEROIDS-FOR-OPHTHALMIC-INJECTION-DEXTENZA-ILUVIE-3928170B17, Corticosteroids for ophthalmic injection (Dextenza, Iluvien, Ozurdex, Retisert, Xipere, Yutiq); CP.PHAR.385

UHC-POL-intravitreal-corticosteroid-implants, Intracanalicular and Intravitreal Corticosteroid Implants

AETNA-CPB-0462, Headaches: Nonsurgical Management

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

UMR-POL-UMR-intravitreal-corticosteroid-implants, Intracanalicular and Intravitreal Corticosteroid Implants

SUREST-POL-SUREST-intravitreal-corticosteroid-implants, Intracanalicular and Intravitreal Corticosteroid Implants

BCBSTN-97959657c5, Dexamethasone Implant (Ozurdex)

`J7312`, Injection, dexamethasone, intravitreal implant, 0.1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

11 Active Policies

Related Codes

Have a follow-up question?

J7312, Injection, dexamethasone, intravitreal implant, 0.1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

11 Active Policies

Related Codes

Have a follow-up question?

`J7312`, Injection, dexamethasone, intravitreal implant, 0.1 mg