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Medical Policy Revision: Ocriplasmin (Jetrea®)

Effective October 26, 2015, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider certain claims for the injectable medication, Ocriplasmin.

Based on the guidelines of our revised medical policy, Ocriplasmin (Jetrea):

  • Claims for services provided on and after October 26, 2015 to patients 18 years of age and older that include procedure code J7316 submitted with ICD-9 diagnosis code 379.27 or ICD-10 diagnosis codes H43.821, H43.822, H43.823, or H43.829 will pend while information required to determine medical necessity is requested and reviewed.
  • Procedure code J7316 submitted on claims for services provided on and after October 26, 2015 to patients 18 years of age and older that include an ICD-9 or ICD-10 diagnosis code other than one of those listed above will be denied as an experimental or investigational service.
  • Procedure code J7316 submitted on claims for services provided on and after October 26, 2015 to patients under 18 years of age will be denied as not medically necessary regardless of the submitted diagnosis.

Review this revised policy in our online Medical Policy Manual.

Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been cancelled or postponed, the changes will be applied to claims for dates of service on and after October 26, 2015.

CPT® is a registered mark of the American Medical Association.

Published on: July 27, 2015, 10:00 a.m. ET
Last updated on: November 24, 2020, 23:40 p.m. ET