Oxervate (cenegermin-bkbj) — Highmark
Neurotrophic keratitis
Initial criteria
- age ≥ 2 years
- Clinical documentation supports a diagnosis of neurotrophic keratitis (ICD-10: H16.231) including reduced corneal sensitivity testing (e.g., cotton swab method, Cochet-Bonnet contact aesthesiometer, or CRCERT-Belmonte non-contact aesthesiometer) AND slit-lamp examination
- Documentation that the member has neurotrophic keratitis in the left eye OR right eye OR both eyes
- Member has experienced therapeutic failure, contraindication, or intolerance to artificial tears
Reauthorization criteria
- Clinical documentation supports diagnosis of neurotrophic keratitis (ICD-10: H16.231) including reduced corneal sensitivity testing (e.g., cotton swab method, Cochet-Bonnet contact aesthesiometer, or CRCERT-Belmonte non-contact aesthesiometer) AND slit-lamp examination
- For neurotrophic keratitis in one eye: affected eye differs from previously approved eye, and member has experienced therapeutic failure, contraindication, or intolerance to artificial tears
- Subsequent courses will not be approved for reauthorization when neurotrophic keratitis affects both eyes
Approval duration
up to 12 weeks per authorization; total therapy should not exceed 8 weeks per eye lifetime