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Triamcinolone Acetonide Injectable Suspension (Xipere) (CPB 1000, reviewed 2026-04-24)
Effective date
Feb 22, 2022
Identified
Aug 18, 2026
Summary
Aetna has established coverage criteria for Xipere (triamcinolone acetonide injectable suspension) for treating macular edema associated with uveitis. Billing teams must now require prior authorization for CPT 67516 and HCPCS J3299 only when the patient has non-infectious uveitis and receives no more than 4 mg (0.1 mL) suprachoroidal injection per eye. All other indications remain experimental and non-covered.
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What to do
Action · 8 steps
01By May 2026 (before next review date): Billing and prior authorization teams must implement the following.
02Update billing system to require prior authorization for CPT 67516 and HCPCS J3299 when billed with diagnosis code H35.81 (covered indication).
03Configure system to DENY claims when H20.031-H20.039 (infectious uveitis codes) are present on the claim for these procedures.
04Add medical necessity checklist to provider encounter forms requiring documentation of: non-infectious uveitis diagnosis, confirmation that dose does not exceed 4 mg (0.1 mL), and ophthalmologist involvement in care.
05Train front desk and billing staff that Xipere for all other indications (diabetic macular edema, macular degeneration, ocular tumors) is NOT covered and must be denied or routed to patient as self-pay.
06Update prior auth templates to verify injection site is suprachoroidal space only.
07Claims lacking proper diagnosis coding or exceeding dose limits will be denied.
08Providers must be ophthalmologists or have ophthalmology consultation documented.
Codes mentioned
67516J3299H35.81H20.031H20.032H20.033H20.034H20.035H20.036H20.037H20.038H20.039
Original notice
Triamcinolone Acetonide Injectable Suspension (Xipere) (CPB 1000, reviewed 2026-04-24)
aetna.com · Always check the source before changing claims.
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