Dexamethasone Ophthalmic Implant (Ozurdex) and Insert (Dextenza) — CPB 0795 | AETNA Coverage Update

Aetna modified CPB 0795 for dexamethasone ophthalmic implant (Ozurdex) and insert (Dextenza), effective December 20, 2025. Here's what billing teams need to act on now.

Aetna, a CVS Health company, updated Clinical Policy Bulletin CPB 0795 to clarify medical necessity criteria, contraindication exclusions, and a critical reimbursement rule for Dextenza (dexamethasone ophthalmic insert) when placed during surgery. The two primary procedure codes affected are CPT 67027 (intravitreal drug delivery system implantation) and CPT 67028 (intravitreal injection of a pharmacologic agent). If your practice bills for retinal, uveitis, or anterior segment services on Aetna plans, this Aetna dexamethasone ophthalmic coverage policy affects your claims today.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna, a CVS Health company
Policy	Dexamethasone Ophthalmic Implant (Ozurdex) and Insert (Dextenza)
Policy Code	CPB 0795
Change Type	Modified
Effective Date	December 20, 2025
Impact Level	High
Specialties Affected	Ophthalmology, Retina, Uveitis, Anterior Segment Surgery
Key Action	Audit charge capture for Dextenza billed same-day as ophthalmic surgery — Aetna will not separately reimburse it

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Aetna Ozurdex and Dextenza Coverage Criteria and Medical Necessity Requirements 2025

The CPB 0795 Aetna system draws a hard line between what's covered and what's not. Medical necessity is approved for three distinct scenarios with Ozurdex (dexamethasone intravitreal implant, billed under CPT 67027 or CPT 67028):

#	Covered Indication Copy
1	Macular edema secondary to branch or central retinal vein occlusion
2	Non-infectious posterior uveitis (such as pars planitis)
3	Diabetic macular edema (DME)

That's it. If the indication isn't on that list, Ozurdex billing for Aetna members will result in a claim denial.

Aetna also specifies absolute contraindications where Ozurdex is considered not medically necessary — even for the three covered indications above. These include ocular or periocular infections (viral, bacterial, or fungal), advanced glaucoma, aphakic eyes with rupture of the posterior lens capsule, anterior chamber intraocular lens (ACIOL) with posterior lens capsule rupture, and any non-intact posterior lens capsule. Document these contraindications clearly in the chart when present — they will come up in audits.

For Dextenza (dexamethasone ophthalmic insert), Aetna recognizes two covered uses. First, ocular inflammation and pain following ophthalmic surgery. Second, ocular itching associated with allergic conjunctivitis — but only after the patient has failed all three of the following, unless contraindicated or causing significant adverse effects: topical ophthalmic antihistamines with mast cell-stabilizing properties, topical ophthalmic mast cell stabilizers, and topical ophthalmic corticosteroids.

The allergic conjunctivitis pathway is a strict step-therapy requirement. Failure of all three drug classes must be documented before Aetna will consider Dextenza medically necessary for that indication. "Tried one, didn't like it" won't cut it on a prior authorization request.

The big reimbursement rule buried in this coverage policy: when Dextenza is placed at the time of ophthalmic surgery, Aetna treats it as a supply integral to the procedure. It is not separately reimbursed. This alone could be driving unbundling denials in your ophthalmology claims right now if your team isn't flagging same-day placements.

Aetna's policy does not detail specific prior authorization requirements within the CPB language itself, but given the step-therapy requirement for Dextenza in allergic conjunctivitis and the narrow medical necessity criteria for Ozurdex, you should verify prior auth requirements for each plan variant before submission. Call the plan or run an eligibility check — don't assume the CPB tells the whole story on auth.

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Aetna Ozurdex and Dextenza Exclusions and Non-Covered Indications

The experimental and investigational list for Ozurdex in this coverage policy is long — 22 named indications. Aetna calls all of these unproven due to insufficient evidence. If you're billing Ozurdex for any of the following, expect a denial:

The note on pseudophakic macular edema is worth reading twice. Irvine-Gass syndrome is not covered — unless the patient is pseudophakic and also has DME. That carve-out is narrow. If you have a pseudophakic DME patient, confirm the DME diagnosis is clearly supported in the record and coded correctly before billing CPT 67028.

Combined cataract surgery plus Ozurdex is also explicitly not covered. The cataract surgery CPT codes 66820 through 66899 (and an extended range beyond that) appear in the policy as "not covered when combined with Ozurdex." Billing CPT 67027 or 67028 alongside a cataract surgery CPT on the same service date for the same patient is a denial waiting to happen.

For Dextenza, the only contraindication exclusion is active ocular infection. That's a narrow carve-out, but it still needs to be checked before billing.

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Coverage Indications at a Glance

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Aetna Dexamethasone Ophthalmic Billing Guidelines and Action Items 2025

The effective date of December 20, 2025 means this policy is live now. These billing guidelines apply to all claims submitted on or after that date.

Copy Action Items

If your practice has a high volume of Aetna ophthalmic surgery cases, loop in your compliance officer before the end of Q1 2026. The same-day Dextenza rule and the combined cataract/Ozurdex exclusion are both areas where retroactive denials could pile up fast.

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CPT, HCPCS, and ICD-10 Codes for Dexamethasone Ophthalmic Implant Under CPB 0795

Covered CPT Codes (When Selection Criteria Are Met)

Code	Type	Description Copy
67027	CPT	Implantation of intravitreal drug delivery system (e.g., ganciclovir implant), includes concomitant removal of vitreous
67028	CPT	Intravitreal injection of a pharmacologic agent (separate procedure)

CPT Codes — Not Covered When Combined with Ozurdex

These cataract surgery CPT codes are related to this policy. Aetna will not cover Ozurdex (CPT 67027 or 67028) when billed on the same claim as any of these codes.

Note: The policy data indicates 30 additional cataract surgery CPT codes beyond those listed above. Confirm the full code list in the source policy at CPB 0795 before finalizing your charge capture edits.

The policy references 1,307 ICD-10-CM codes. Because the source data did not include individual code descriptions for the full ICD-10 list, confirm applicable diagnosis codes directly in CPB 0795 at app.payerpolicy.org/p/aetna/0795 or in your payer contract portal.

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