About this policy
Jurisdiction: JM Part B. States: North Carolina, South Carolina, Virginia, West Virginia. Type: Active LCD
Coverage indications
Background : Dextenza ® (Ocular Therapeutix, Inc., Bedford, MA, USA) is a resorbable hydrogel corticosteroid implant indicated for treating ocular inflammation and pain after ophthalmic surgery. After surgery, the insert is placed in the lower lacrimal punctum and into the canaliculus. The insert releases 0.4 mg of dexamethasone over 30 days onto the eye surface. It is made from a polyethylene glycol-based hydrogel conjugated with fluorescein, which is resorbable and does not require removal. Anterior chamber inflammation (10%) and elevated intraocular pressure (IOP) (6%) were the most common adverse reactions. IOP should be monitored during treatment. Dextenza ® should not be used in patients with active corneal, conjunctival, or canalicular infections, including epithelial herpes simplex keratitis (dendritic keratitis), vaccinia, varicella, mycobacterial infections, fungal eye diseases, and dacryocystitis. Dextenza® is an alternative to topical corticosteroid preparations (e.g., eye drops) used to reduce pain and inflammation after cataract surgery. Persistent inflammation may lead to complications, such as increased IOP, cystoid macular edema, secondary glaucoma, delayed recovery, ocular pain, and reduced vision. However, patients may have difficulty delivering the correct dose when using topical eye drop preparations; eye drops may need to be tapered over time and are associated with poor patient adherence. 1 The elderly population, in particular, typically has more difficulty using eye drops to deliver topical corticosteroids after eye surgery. Coverage Indications and limitations : Palmetto GBA considers the use of the Dextenza® dexamethasone insert reasonable and necessary for the treatment of ocular inflammation and pain following ophthalmic surgery. Dextenza® is contraindicated in patients with the following conditions: active corneal, conjunctival or canalicular infections, including epithelial herpes simplex keratitis (dendritic keratitis), vaccinia, varicella mycobacterial infections of the eye fungal diseases of the eye dacryocystitis.
Codes in this policy
Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.