Ozurdex® (dexamethasone intravitreal implant)

Code(s): J7312

Benefit: Medical

Notes:

  • Intraocular Implant: 0.7 MG 
  • No authorization required
  • Covered only for the following diagnoses:

E08.311, Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema
E08.3211-E08.3213, Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema
E08.3311-E08.3313, Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema
E08.3411-E08.3413, Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema
E08.3511-E08.3513, Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema
E09.311, Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular edema
E09.3211- E09.3213, Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E09.3311-E09.3313, Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
E09.3411-E09.3413, Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
E09.3511-E09.3513, Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema
E10.311, Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema
E10.321 –E10.3213, Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E10.3311-E10.3313, Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
E10.3411-E10.3413, Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
E10.3511-E10.3513, Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema
E10.3511-E10.3513, Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema
E11.311, Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema
E11.3211-E11.3213, Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E11.3311- E11.3313, Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
E11.3411-E11.3413, Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
E11.3511-E11.353, Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema
E13.3111-E13.3113, Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema
E13.3211-E13.3213, Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E13.3311-E13.3313, Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
E13.3411-E13.3413, Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
E13.3511-E13.353, Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema
H30.001-H30.93, Chorioretinal inflammation
H34.8110, Central retinal vein occlusion, right eye, with macular edema
H34.8120,  Central retinal vein occlusion, left eye, with macular edema
H34.8130,  Central retinal vein occlusion, bilateral, with macular edema
H34.8310,  Tributary (branch) retinal vein occlusion, right eye, with macular edema
H34.8320,  Tributary (branch) retinal vein occlusion, left eye, with macular edema
H34.8330,  Tributary (branch) retinal vein occlusion, bilateral, with macular edema