Does J7313 require prior authorization?

Yes, J7313 requires prior authorization (medium confidence). Conditional coverage; review criteria to confirm PA need.

What is the Medicare reimbursement rate for J7313?

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

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`J7313`, Injection, fluocinolone acetonide, intravitreal implant (iluvien), 0.01 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

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.

Maintain medical record documentation showing prior course of corticosteroid treatment for DME and documentation of IOP response (e.g., ophthalmology notes and IOP measurements).

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."

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.

13 Active Policies

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

HEALTHPARTNERS-CC-ENTRY-207224, Fluocinolone acetonide implants (Iluvien, Retisert and Yutiq)

MULTI

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-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

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-7c983e58df, Fluocinolone Acetonide Implant (Iluvien)

A54750, Billing and Coding: FDA approves Iluvien for Diabetic Macular Edema

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J7313, Injection, fluocinolone acetonide, intravitreal implant (iluvien), 0.01 mg