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Please perform a formulary drug search on your patient’s member ID to ensure the prescription drug is covered under their benefit plan. The medication(s) in this medical policy may not be covered under a specific member’s benefit plan.
DESCRIPTIONAllergic conjunctivitis is the most common form of allergic ocular disease, and is divided into three subtypes (acute, seasonal, and perennial), all of which have a similar pathophysiology. Treatment of each of these subtypes is based on frequency and severity of symptoms. Several classes of ophthalmic products are available for the treatment of allergic conjunctivitis including antihistamine/vasoconstrictors, mast-cell stabilizers, nonsteroidal anti-inflammatory drugs, and corticosteroids.
Antihistamine/decongestant combinations are reasonable first options for allergic conjunctivitis because they are available OTC and are relatively inexpensive, but should are only recommended for short term use (no more than 3 days) due to the potential for decongestant rebound congestion.
Agents with multiple actions have become popular because they provide immediate relief (antihistamine and/or anti-inflammatory effects) and prophylaxis (mast cell stabilizer effect) in one medication. In addition these agents have been shown to be safe and effective for both short and long term use for treatment of mild to moderately severe allergic conjunctivitis. Comparative trials among agents possessing multiple actions have not been conducted. The availability of OTC ketotifen products provides a lower cost option among this medication category.
Mast cell stabilizers are effective, but are less popular because they require more frequent dosing and have a delayed onset of action (5-14 days). Ophthalmic NSAIDs are generally considered to be less effective than other medical therapies for allergic conjunctivitis, but are useful when edema or vasodilation is present. Ophthalmic corticosteroids should only be used for short “pulse therapy” when antihistamines and mast cell stabilizers provide inadequate therapy. Due to the potential for severe, vision threatening, side effects, corticosteroids should only be administered by ophthalmologists.
In addition to their use for allergic conjunctivitis, several ophthalmic corticosteroids and ophthalmic non-steroidal anti-inflammatory products are FDA-approved for the treatment of ocular pain and/or inflammation. Patients undergoing ocular surgery may require the short-term use of anti-inflammatory ophthalmic products to prevent complications and assist in proper healing. Both generic and branded products are currently available.
POLICYAlomide, Alocril, Bepreve, Emadine, Lastacraft, and Pataday will be approved when there is documentation of treatment failure, intolerance, or contraindication to trials of OTC ketotifen AND azelastine, cromolyn, or epinastine.
Acuvail, Bromday, and Nevanac will be approved when there is documentation of treatment failure, intolerance, or contraindication to trials of diclofenac AND bromfenac or ketorolac.
POLICY EXCEPTIONSOphthalmic Allergy/Anti-inflammatory prior authorization is not required for Federal Employee Program (FEP) and State Health Plan members.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
01/01/2014: New policy added.
08/03/2015: Code Reference section updated for ICD-10.
05/31/2016: Policy number L.5.01.458 added. Investigative definition updated in Policy Guidelines section.
08/09/2016: Approved by Pharmacy & Therapeutics (P&T) Committee.
SOURCE(S)1. Topical treatment of allergic conjunctivitis, the role of OTC ketotifen (Zaditor, Alaway). Pharmacist’s Letter / Prescriber’s Letter. Therapeutic Research Center.
January 2007. Available from: http://www.pharmacistletter.com.
2. Dana R. Allergic Conjunctivitis. Up to Date®. Accessed Oct 2011. Available from: http://www.uptodate.com.
3. Bielory BP. et al. Treatment of Seasonal Allergic Conjunctivitis with Opthalmic Corticosteroids: In Search of the Prefect Ocular Corticosteroids in the Treatment of Allergic conjunctivitis. Curr Opin Allergy Clin Immunol. 2010;10(5):469-477.
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.