Prior authorization request form Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 4|01|2026 POLICY LAST REVIEWED: 1|21|2026 OVERVIEW Patient’s poor adherence to topical eye medication for the treatment of glaucoma has led to the development of various drug-eluting devices. One such device is the anterior segment intraocular nonbiodegradable drug- eluting system. MEDICAL CRITERIA Not applicable
PRIOR AUTHORIZATION Not applicable
POLICY STATEMENT Medicare Advantage Plans and Commercial Products Implantation of anterior segment intraocular non‐biodegradable drug eluting system is covered. COVERAGE Benefits may vary between groups/contracts. Please refer to the Benefit Booklet, Evidence of Coverage or Subscriber Agreement for applicable not medically necessary/not covered benefits/coverage. BACKGROUND Drug-eluting devices are in development to combat low patient adherence with medications since many eye drops require multiple doses daily. These types of devices are implanted or inserted into the eye temporarily and purportedly release a steady dose of medication until they are removed, dissolve or are washed out via the tear duct.
The procedure to implant the anterior segment intraocular non-biodegradable drug eluting system is performed from an internal approach. The implant is anchored through the trabecular meshwork into the sclera that elutes the drug over an extended period to lower intraocular pressure. Per the manufacturer, Glaukos, iDose TR® is a sustained release micro-invasive intracameral implant indicated for the reduction of intraocular pressure in patients with open angle glaucoma or ocular hypertension. It is designed to continuously deliver therapeutic levels of a proprietary preservative-free formulation of travoprost, a prostaglandin analog from within the eye for extended periods of time. It was FDA approved under 505(b)(2) New Drug Application on December 13, 2023. CODING Medicare Advantage Plans and Commercial Products The following codes are not covered for Medicare Advantage Plans and not medically necessary for Commercial Products:
0660T Implantation of anterior segment intraocular nonbiodegradable drug-eluting system, internal approach J7355 Injection, travoprost, intracameral implant, 1 microgram RELATED POLICIES Removal of Implantable Devices DRAFT Medical Coverage Policy | Implantation of Anterior Segment Intraocular Nonbiodegradable Drug-Eluting System

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

PUBLISHED Provider Update, March 2026 Provider Update, August 2024

REFERENCES

1. American Academy of Ophthalmology (AAO). American Academy of Ophthalmology and American Glaucoma Society Glaucoma ICD-10-CM quick reference guide. https://www.aao.org. Published February 2015. Updated June 2019.
2. American Academy of Ophthalmology (AAO). Ophthalmic Technology Assessment. Novel glaucoma procedures. https://www.aao.org. Published July 2011.
3. American Academy of Ophthalmology (AAO). Ophthalmic Technology Assessment. Pediatric glaucoma surgery. https://www.aao.org. Published November 2014.
4. American Academy of Ophthalmology (AAO). Preferred Practice Pattern. Cataract in the adult eye. https://www.aao.org. Published October 13, 2021.
5. American Academy of Ophthalmology (AAO). Preferred Practice Pattern. Primary angle-closure disease. https://www.aao.org. Published September 12, 2020.
6. American Academy of Ophthalmology (AAO). Preferred Practice Pattern. Primary open-angle glaucoma. https://www.aao.org. Published September 12, 2020.
7. American Glaucoma Society (AGS). American Glaucoma Society Position Paper. Microinvasive glaucoma surgery. https://www.americanglaucomasociety.net. Published January 24, 2020.
8. American Glaucoma Society (AGS). Position Statement. AGS – ACRS Definition of refractory glaucoma. https://www.americanglaucomasociety.net. Published August 19, 2020.
9. Ang, B, Lim S, Dorairaj, S. Intra-operative optical coherence tomography in glaucoma surgery – a systematic review. Eye. 2020;34:168-177.
10. Bicket A, Le J, Azuara-Blanco A, et al. Minimally invasive glaucoma surgical techniques for open-angle glaucoma: an overview of Cochrane systematic reviews and network meta-analysis. JAMA Ophthalmol. 2021;139(9):983-989.
11. ClinicalKey. Coulon S, Do AT, Panarelli JF. Microinvasive glaucoma surgeries. In: Yanoff M, Duker JS. Ophthalmology. 6th ed. Elsevier; 2023:1074-1080.e1. https://www.clinicalkey.com.
12. UpToDate, Inc. Angle-closure glaucoma. https://www.uptodate.com. Updated February 2024.
13. UpToDate, Inc. Open-angle glaucoma: treatment. https://www.uptodate.com. Updated February

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    This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association.

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