June 2021

Dear eye care professional:

Thank you for your participation in the Versant Health panel of eye care professionals. As part of our ongoing commitment to open lines of communication, we are sending this letter to inform you of updates and additional medical policies recently approved by the Versant Health Utilization Management Committee.

The following policies have been added or updated with effective dates as noted:

1. 1300.00 Cataract Surgery - Criteria revised for bilateral sequential cataract surgery, allowing a functional impairment of glare vision of 20/50 or worse in each eye as an acceptable proxy for a BCVA Snellen of 20/50 in each eye; eliminated requirement for bilateral sequential surgery to require a functional assessment to be documented for each eye. Effective 9/1/2021.

2. 1309.00 Medically Necessary Contact Lenses - Criteria restated for high ametropia metrics as applying to any meridian rather than spherical equivalent.

3. 1311.00 Adult Strabismus Surgery - No criteria changes. Effective 7/1/2021.

4. 1316.00 Eye Exam - No criteria changes. Effective 7/1/2021.

5. 1317.00 Intravitreal Injections - Reorganized policy by disease entities and drugs, plus incorporated the following criteria revisions:

a. deleted Verteporfin Photodynamic Therapy criteria (J3396) and redrafted as separate policy 1345.00 Photodynamic Therapy.
b. states that step therapy protocols are only applicable as required by individual healthplan clients;
c. adds exudative macular degeneration as an indication for A-VEGF;
d. adds off label use of Retisert for diabetic macular edema;
e. adds use of Yutiq for diabetic macular edema;
f. adds additional criteria for macular hole of at least 400 microns for Jetrea;
g. adds restriction of Jetrea to single treatment.

- effective 9/1/2021

6. 1323.00 Experimental and Investigational Services - No criteria changes. Effective 7/1/2021

7. 1325.00 Botulinum Toxin - No criteria changes. Effective 7/1/2021.

8. 1328.00 Kerataconus and Related Corneal Ectasias – Criteria revised for corneal cross linking with deletion of reference to contact lens therapy; criteria revised for lamellar keratoplasty and penetrating keratoplasty, deleted requirements for increases in keratometry meridian and astigmatism. Effective 9/1/2021.

9. 1329.00 Pterygium Surgery - No criteria changes. Effective 7/1/2021.

10. 1330.00 Specialty Spectacle Lenses - Restated the metric for high ametropia for poly carbonate lenses to any meridian from “spherical equivalent. Adds CPT codes for colored and blue blocking lens add-ons. Effective 9/1/2021.

11. 1333.00 Refractive Surgery - Restated the metric for high ametropia for poly carbonate lenses to any meridian from “spherical equivalent. Effective 9/1/2021.

12. 1336.00 Telemedicine - No criteria changes. Effective 7/1/2021.

13. 1342.00 Remote Monitoring of Intermediate Stage Macular Degeneration - No criteria changes. Effective 7/1/2021.

14. 1345.00 Verteporfin Photodynamic Therapy –PTD therapy removed from policy 1317.00 (Intravitreal injections) and republished as a new, separate policy. Effective 9/1/2021.

Versant Health, which brings you the Superior Vision network and the Davis Vision network, maintains and provides access to our policies which can be accessed via the Eye Care Professional Portal located at superiorvision.com and davisvision.com. The medical policies can be found by selecting “Health Plans” and then “Medical Management” from the left side navigation bar on the portal home page. Additionally, the most current Prior Authorization list can be found in the same location.

We greatly appreciate the professional services which you render to our members. Thank you for being a Versant Health eye care professional.



Mark C. Ruchman, MD
Chief Medical Officer