A fluocinolone acetonide intravitreal implant 0.59 mg (Retisert®) may be considered medically necessary for the treatment of:
Chronic noninfectious intermediate, posterior, or panuveitis
A fluocinolone acetonide intravitreal implant 0.19 mg (Iluvien®) may be considered medically necessary for the treatment of:
Diabetic macular edema in patients who have been previously treated with a course of corticosteroids and did not have a clinically significant rise in intraocular pressure.
A dexamethasone intravitreal implant 0.7 mg (Ozurdex™) may be considered medically necessary for the treatment of:
Noninfectious ocular inflammation, or uveitis, affecting the intermediate or posterior segment of the eye, OR
Macular edema following branch or central retinal vein occlusion, OR
Diabetic macular edema.
A punctum dexamethasone insert 0.4 mg (Dextenza®) may be considered medically necessary for the treatment of
Ocular inflammation and pain following ophthalmic surgery
A fluocinolone acetonide intravitreal implant 0.59 mg (Retisert®) or 0.19 mg (Iluvien®) or dexamethasone intravitreal implant 0.7 mg (Ozurdex™) is considered investigational for the treatment of
Birdshot retinochoroidopathy,OR
Cystoid macular edema related to retinitis pigmentosa,OR
Idiopathic macular telangiectasia type 1,OR
Postoperative macular edema,OR
Circumscribed choroidal hemangiomas,OR
Proliferative vitreoretinopathy,OR
Radiation retinopathy,OR
Prophylaxis of cystoid macular edema in patients with noninfectious intermediate uveitis or posterior uveitis and cataract undergoing cataract surgery
A fluocinolone acetonide intravitreal implant 0.18 mg (Yutiq®) is considered investigational for the treatment of chronic noninfectious posterior uveitis affecting the posterior segment of the eye
All other uses of a corticosteroid intravitreal implant are considered investigational.
