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08.02.44, Revakinagene taroretcel-lwey (Encelto®)
Effective date
Dec 29, 2025
Identified
Jun 19, 2026
Summary
Independence Blue Cross reissued Policy 08.02.44 on 12/29/2025 with no substantive changes to coverage criteria for Encelto® (revakinagene taroretcel-lwey), a newly FDA-approved gene therapy for idiopathic macular telangiectasia type 2 (MacTel). The policy establishes medical necessity requirements, documentation standards, and coverage limitations for this high-cost ophthalmologic implant procedure.
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What to do
Action · 8 steps
01By 12/29/2025: Billing team must implement the following for Encelto® claims.
02Add HCPCS code J3403 to the billing system with coverage designation as 'Medically Necessary' under Policy 08.02.44.
03Map ICD-10 diagnosis codes H35.071, H35.072, and H35.073 (retinal telangiectasis) to this policy.
04Update prior authorization workflows to require documentation of all five medical necessity criteria before claim submission, including: ophthalmologic diagnosis confirmation via FAG/OCT/OCTA, BCVA measurement (54-letter ETDRS or 20/80 Snellen minimum), exclusion of contraindications (infections, hypersensitivity, glaucoma, severe diabetic retinopathy, uveitis, other confounding ocular disease), OCT confirmation of absence of intraretinal hyperreflectivity and neovascularization, and verification patient has not undergone vitrectomy, keratoplasty, trabeculectomy, trabeculoplasty, lens removal within 3 months, or YAG laser within 4 weeks.
05Flag claims for prior authorization denial if any exclusion criteria are present or if patient has received previous Encelto® implantation in the affected eye.
06Create encounter form checklist for ophthalmology providers to ensure required documentation is captured.
07Failure to obtain authorization prior to implantation will result in claim denials.
08Note: This is a reissue with no coverage changes, so existing authorizations remain valid under the prior policy version.
Codes mentioned
J3403H35.071H35.072H35.073
Original notice
08.02.44, Revakinagene taroretcel-lwey (Encelto®)
medpolicy.ibx.com · Always check the source before changing claims.
Related changes
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