Intravitreal Injections

Policy ID: I-94-047

Section: Injections

Effective Date: August 29, 2022

Revised Date: March 12, 2024

Revision Effective Date: April 01, 2024

Last Reviewed: March 19, 2024

Applies To: Commercial and Medicaid Expansion

Description

Vascular endothelial growth factor (VEGF) has been implicated in the pathogenesis of a variety of ocular vascular conditions. The macula, with the fovea at its center, has the highest photoreceptor concentration and is where visual detail is discerned. The anti-VEGF agent's brolucizumab-dbll (Beovu®), ranibizumab (Lucentis™), ranibizumab-eqrn (Cimerli ^TM ), ranibizumab-nuna (Byooviz ^TM ), ranibizumab injection ocular implant (Susvimo ^TM ), bevacizumab (Avastin®), aflibercept (Eylea ™ and Eylea HD®), and faricimab-svoa (Vabysmo ^TM ) are used to treat certain ocular disorders and are given by intravitreal injection.

Geographic atrophy (GA) is a late stage of dry age-related macular degeneration (AMD). Pegcetacoplan (Syfovre ^TM ) and (avacincaptad pegol (Izervay ^TM ) are intravitreal injections for the treatment of GA that works by slowing progression of GA lesions that can permanently damage the macula.

Policy Application

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the www.fepblue.org website.

A flibercept (Eylea) may be considered medically necessary for the treatment of individuals with ANY ONE of the following conditions:

Diabetic macular edema (DME); or
Diabetic retinopathy in patients with r without DME; or
Macular edema following retinal vein occlusion (RVO); or
Retinopathy of prematurity; or
Neovascular (wet) age-related macular degeneration (AMD).

Reauthorization Criteria

Continuation of aflibercept (Eylea) may be considered medically necessary when there is positive clinical response (e.g., improvement in visual acuity).

The use of aflibercept (Eylea) for all other indications not listed on this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature.

Procedure Code

J0178

Aflibercept (Eylea HD) may be considered medically necessary for the treatment of individuals with ANY ONE of the following conditions:

Diabetic Macular Edema (DME); or
Diabetic Retinopathy (DR); or
Neovascular (wet) AMD.

Reauthorization Criteria

Continuation of aflibercept (Eylea) may be considered medically necessary when there is positive clinical response (e.g. improvement in visual acuity) ,

The use of aflibercept (Eylea HD) for all other indications not listed on this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature.

Procedure Code

J0177

Brolucizumab-dbll (Beovu) may be considered medically necessary for the treatment of individuals with:

Neovascular (wet) AMD.

Reauthorization Criteria

Continuation of brolucizumab-dbll (Beovu) may be considered medically necessary when there is positive clinical response (e.g., improvement in visual acuity).

The use of brolucizumab-dbll (Beovu) for all other indications not listed on this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature.

Procedure Code

J0179

Ranibizumab (Lucentis) or ranibizumab-eqrn (Cimerli) may be considered medically necessary for the treatment of individuals with ANY ONE of the following conditions:

Diabetic macular edema (DME); or
Diabetic retinopathy in individuals with or without DME; or
Macular edema following RVO; or
Myopic Choroidal Neovascularization (mCNV); or
Neovascular (wet) AMD.

Reauthorization Criteria

Continuation of ranibizumab (Lucentis) or ranibizumab-eqrn (Cimerli) may be considered medically necessary when there is positive clinical response (e.g., improvement in visual acuity) .

The use of ranibizumab (Lucentis) or ranibizumab-eqrn (Cimerli) for all other indications not listed on this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature.

Procedure Codes

J2778

Q5128

Ranibizumab-nuna (Byooviz) may be considered medically necessary for the treatment of individuals with ANY ONE of the following conditions:

Macular Edema Following Retinal Vein Occlusion (RVO) ; or
Myopic Choroidal Neovascularization ; or
Neovascular (Wet) Age-Related Macular Degeneration.

Reauthorization Criteria

Continuation of ranibizumab-nuna (Byooviz) may be considered medically necessary when there is positive clinical response (e.g., improvement in visual acuity) .

The use of ranibizumab-nuna (Byooviz) for all other indications not listed on this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature.

Procedure Code

Q5124

Ranibizumab (Susvimo) intravitreal injection via ocular implant may be considered medically necessary for the treatment of individuals with:

Neovascular (wet) Age-related Macular Degeneration (AMD)

Reauthorization Criteria

Continuation of ranibizumab (Susvimo) may be considered medically necessary when there is positive clinical response (e.g., improvement in visual acuity) .

The use of ranibizumab (Susvimo) for all other indications not listed on this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature.

Procedure Code

J2779

Faricimab-svoa (Vabysmo) may be considered medically necessary for the treatment of individuals with ANY ONE of the following conditions:

Neovascular (Wet) (AMD); or
Diabetic Macular Edema (DME); or
Macular edema following RVO.

Reauthorization Criteria

Continuation of faricimab-svoa (Vabysmo) may be considered medically necessary when there is positive clinical response (e.g., improvement in visual acuity) .

The use of faricimab-svoa (Vabysmo) for all other indications not listed on this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature.

Procedure Code

J2777

Pegcetacoplan injection (Syfovre) may be considered medically necessary for the treatment of individuals with the following condition:

Geographic atrophy (GA) secondary to age-related macular degeneration (AMD).

Reauthorization Criteria

Continuation of pegcetacoplan injection (Syfovre) may be considered medically necessary when there is positive clinical response (e.g., reduction in rate of GA lesion growth documented by difference in mm²).

The use of pegcetacoplan injection (Syfovre) for all other indications not listed on this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature.

Procedure Code

J2781

Avacincaptad pegol intravitreal solution (Izervay) may be considered medically necessary for the treatment of individuals with the following condition:

Geographic atrophy (GA) secondary to nonexudative (dry) AMD; and

Reauthorization Criteria

Additional injections of avacincaptad pegol (Izervay) after the initial 12 months are considered experimental/investigational, and therefore, non-covered. Scientific evidence does not support use beyond 12 months.

The use of avacincaptad pegol (Izervay) for all other indications not listed on this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature.

Procedure Code

J2782

NOTE: In addition to the above criteria, product specific dosage and/or frequency limits may apply in accordance with the United States Food and Drug Administration (U.S. FDA)-approved product prescribing information, national compendia, Centers for Medicare and Medicaid Services (CMS) and other peer reviewed resources or evidence-based guidelines.

Diagnosis Codes

Covered Diagnosis Codes for Procedure Code J0179

E08.311

E08.3211

E08.3212

E08.3213

E08.3219

E08.3311

E08.3312

E08.3313

E08.3319

E08.3411

E08.3412

E08.3413

E08.3419

E08.3511

E08.3512

E08.3513

E08.3519

E09.311

E09.3211

E09.3212

E09.3213

E09.3219

E09.3311

E09.3312

E09.3313

E09.3319

E09.3411

E09.3412

E09.3413

E09.3419

E09.3511

E09.3512

E09.3513

E09.3519

E10.311

E10.319

E10.3211

E10.3212

E10.3213

E10.3219

E10.3291

E10.3292

E10.3293

E10.3299

E10.3311

E10.3312

E10.3313

E10.3319

E10.3411

E10.3412

E10.3413

E10.3419

E10.3511

E10.3512

E10.3513

E10.3519

E11.311

E11.319

E11.3211

E11.3212

E11.3213

E11.3219

E11.3311

E11.3312

E11.3313

E11.3319

E11.3411

E11.3412

E11.3413

E11.3419

E11.3511

E11.3512

E11.3513

E11.3519

E13.311

E13.3211

E13.3212

E13.3213

E13.3219

E13.3311

E13.3312

E13.3313

E13.3319

E13.3411

E13.3412

E13.3413

E13.3419

E13.3511

E13.3512

E13.3513

E13.3519

H35.3210

H35.3211

H35.3212

H35.3213

H35.3220

H35.3221

H35.3222

H35.3223

H35.3230

H35.3231

H35.3232

H35.3233

H35.3290

H35.3291

H35.3292

H35.3293

Covered Diagnosis Codes for Procedure Code J2779

H35.3210

H35.3211

H35.3212

H35.3213

H35.3220

H35.3221

H35.3222

H35.3223

H35.3230

H35.3231

H35.3232

H35.3233

H35.3290

H35.3291

H35.3292

H35.3293

Covered Diagnosis Codes for Procedure Code J0178

E08.311

E08.319

E08.3211

E08.3212

E08.3213

E08.3219

E08.3291

E08.3292

E08.3293

E08.3299

E08.3311

E08.3312

E08.3313

E08.3319

E08.3391

E08.3392

E08.3393

E08.3399

E08.3411

E08.3412

E08.3413

E08.3419

E08.3491

E08.3492

E08.3493

E08.3499

E08.3511

E08.3512

E08.3513

E08.3519

E08.3521

E08.3522

E08.3523

E08.3529

E08.3531

E08.3532

E08.3533

E08.3539

E08.3541

E08.3542

E08.3543

E08.3549

E08.3551

E08.3552

E08.3553

E08.3559

E08.3591

E08.3592

E08.3593

E08.3599

E09.311

E09.319

E09.3211

E09.3212

E09.3213

E09.3219

E09.3291

E09.3292

E09.3293

E09.3299

E09.3311

E09.3312

E09.3313

E09.3319

E09.3391

E09.3392

E09.3393

E09.3399

E09.3411

E09.3412

E09.3413

E09.3419

E09.3491

E09.3492

E09.3493

E09.3499

E09.3511

E09.3512

E09.3513

E09.3519

E09.3521

E09.3522

E09.3523

E09.3529

E09.3531

E09.3532

E09.3533

E09.3539

E09.3541

E09.3542

E09.3543

E09.3549

E09.3551

E09.3552

E09.3553

E09.3559

E09.3591

E09.3592

E09.3593

E09.3599

E10.311

E10.319

E10.3211

E10.3212

E10.3213

E10.3219

E10.3291

E10.3292

E10.3293

E10.3299

E10.3311

E10.3312

E10.3313

E10.3319

E10.3391

E10.3392

E10.3393

E10.3399

E10.3411

E10.3412

E10.3413

E10.3419

E10.3491

E10.3492

E10.3493

E10.3499

E10.3511

E10.3512

E10.3513

E10.3519

E10.3521

E10.3522

E10.3523

E10.3529

E10.3531

E10.3532

E10.3533

E10.3539

E10.3541

E10.3542

E10.3543

E10.3549

E10.3551

E10.3552

E10.3553

E10.3559

E10.3591

E10.3592

E10.3593

E10.3599

E11.311

E11.319

E11.3211

E11.3212

E11.3213

E11.3219

E11.3291

E11.3292

E11.3293

E11.3299

E11.3311

E11.3312

E11.3313

E11.3319

E11.3391

E11.3392

E11.3393

E11.3399

E11.3411

E11.3412

E11.3413

E11.3419

E11.3491

E11.3492

E11.3493

E11.3499

E11.3511

E11.3512

E11.3513

E11.3519

E11.3521

E11.3522

E11.3523

E11.3529

E11.3531

E11.3532

E11.3533

E11.3539

E11.3541

E11.3542

E11.3543

E11.3549

E11.3551

E11.3552

E11.3553

E11.3559

E11.3591

E11.3592

E11.3593

E11.3599

E13.311

E13.319

E13.3211

E13.3212

E13.3213

E13.3219

E13.3291

E13.3292

E13.3293

E13.3299

E13.3311

E13.3312

E13.3313

E13.3319

E13.3391

E13.3392

E13.3393

E13.3399

E13.3411

E13.3412

E13.3413

E13.3419

E13.3491

E13.3492

E13.3493

E13.3499

E13.3511

E13.3512

E13.3513

E13.3519

E13.3521

E13.3522

E13.3523

E13.3529

E13.3531

E13.3532

E13.3533

E13.3539

E13.3541

E13.3542

E13.3543

E13.3549

E13.3551

E13.3552

E13.3553

E13.3559

E13.3591

E13.3592

E13.3593

E13.3599

H34.8110

H34.8120

H34.8130

H34.8190

H34.8310

H34.8320

H34.8330

H34.8390

H35.101

H35.102

H35.103

H35.109

H35.141

H35.142

H35.143

H35.149

H35.151

H35.152

H35.153

H35.159

H35.161

H35.162

H35.163

H35.169

H35.3210

H35.3211

H35.3212

H35.3213

H35.3220

H35.3221

H35.3222

H35.3223

H35.3230

H35.3231

H35.3232

H35.3233

H35.3290

H35.3291

H35.3292

H35.3293

Covered Diagnosis Codes for Procedure Codes J2778, Q5128

E08.311

E08.319

E08.3191

E08.3211

E08.3212

E08.3213

E08.3219

E08.3291

E08.3292

E08.3293

E08.3299

E08.3311

E08.3312

E08.3313

E08.3319

E08.3391

E08.3392

E08.3393

E08.3399

E08.3411

E08.3412

E08.3413

E08.3419

E08.3491

E08.3492

E08.3493

E08.3499

E08.3511

E08.3512

E08.3513

E08.3519

E08.3521

E08.3522

E08.3523

E08.3529

E08.3531

E08.3532

E08.3533

E08.3539

E08.3541

E08.3542

E08.3543

E08.3549

E08.3551

E08.3552

E08.3553

E08.3559

E08.3591

E08.3592

E08.3593

E08.3599

E09.311

E09.319

E09.3211

E09.3212

E09.3213

E09.3219

E09.3291

E09.3292

E09.3293

E09.3299

E09.3311

E09.3312

E09.3313

E09.3319

E09.3391

E09.3392

E09.3393

E09.3399

E09.3411

E09.3412

E09.3413

E09.3419

E09.3491

E09.3492

E09.3493

E09.3499

E09.3511

E09.3512

E09.3513

E09.3519

E10.311

E10.3211

E10.3212

E10.3213

E10.3219

E10.3311

E10.3312

E10.3313

E09.3521

E09.3522

E09.3523

E09.3529

E09.3531

E09.3532

E09.3533

E09.3539

E09.3541

E09.3542

E09.3543

E09.3549

E09.3551

E09.3552

E09.3553

E09.3559

E09.3591

E09.3592

E09.3593

E09.3599

E10.319

E10.3291

E10.3292

E10.3293

E10.3299

E10.3319

E10.3391

E10.3392

E10.3393

E10.3399

E10.3411

E10.3412

E10.3413

E10.3419

E10.3491

E10.3492

E10.3493

E10.3499

E10.3511

E10.3512

E10.3513

E10.3519

E10.3521

E10.3522

E10.3523

E10.3529

E10.3531

E10.3532

E10.3533

E10.3539

E10.3541

E10.3542

E10.3543

E10.3549

E10.3551

E10.3552

E10.3553

E10.3559

E10.3591

E10.3592

E10.3593

E10.3599

E11.311

E11.319

E11.3211

E11.3212

E11.3213

E11.3219

E11.3291

E11.3292

E11.3293

E11.3299

E11.3311

E11.3312

E11.3313

E11.3319

E11.3391

E11.3392

E11.3393

E11.3399

E11.3411

E11.3412

E11.3413

E11.3419

E11.3491

E11.3492

E11.3493

E11.3499

E11.3511

E11.3512

E11.3513

E11.3519

E11.3521

E11.3522

E11.3523

E11.3529

E11.3531

E11.3532

E11.3533

E11.3539

E11.3541

E11.3542

E11.3543

E11.3549

E11.3551

E11.3552

E11.3553

E11.3559

E11.3591

E11.3592

E11.3593

E11.3599

E13.311

E13.319

E13.3211

E13.3212

E13.3213

E13.3219

E13.3291

E13.3292

E13.3293

E13.3299

E13.3311

E13.3312

E13.3313

E13.3319

E13.3391

E13.3392

E13.3393

E13.3399

E13.3411

E13.3412

E13.3413

E13.3419

E13.3491

E13.3492

E13.3493

E13.3499

E13.3511

E13.3512

E13.3513

E13.3519

E13.3521

E13.3522

E13.3523

E13.3529

E13.3531

E13.3532

E13.3533

E13.3539

E13.3541

E13.3542

E13.3543

E13.3549

E13.3551

E13.3552

E13.3553

E13.3559

E13.3591

E13.3592

E13.3593

E13.3599

H34.8110

H34.8120

H34.8130

H34.8190

H34.8310

H34.8320

H34.8330

H34.8390

H35.051

H35.052

H35.053

H35.059

H35.3210

H35.3211

H35.3212

H35.3213

H35.3220

H35.3221

H35.3222

H35.3223

H35.3230

H35.3231

H35.3232

H35.3233

H35.3290

H35.3291

H35.3292

H35.3293

H35.81

H44.2A1

H44.2A2

H44.2A3

H44.2A9

Covered Diagnosis Codes for Procedure Code Q5124

H34.8110

H34.8111

H34.8112

H34.8120

H34.8121

H34.8122

H34.8130

H34.8131

H34.8132

H34.8190

H34.8191

H34.8192

H34.8310

H34.8311

H34.8312

H34.8320

H34.8321

H34.8322

H34.8330

H34.8390

H35.3210

H35.3211

H35.3212

H35.3213

H35.3220

H35.3221

H35.3222

H35.3223

H35.3230

H35.3231

H35.3232

H35.3233

H35.3290

H35.3291

H35.3292

H35.3293

H44.2A1

H44.2A2

H44.2A3

H44.2A9

Covered Diagnosis Codes for Procedure Code J2777

E08.311

E08.319

E08.3211

E08.3212

E08.3213

E08.3219

E08.3291

E08.3292

E08.3293

E08.3299

E08.3311

E08.3312

E08.3313

E08.3319

E08.3391

E08.3392

E08.3393

E08.3399

E08.3411

E08.3412

E08.3413

E08.3419

E08.3491

E08.3492

E08.3493

E08.3499

E08.3511

E08.3512

E08.3513

E08.3519

E08.3591

E08.3592

E08.3593

E08.3599

E08.37X1

E08.37X2

E08.37X3

E08.37X9

E09.311

E09.319

E09.3211

E09.3212

E09.3213

E09.3219

E09.3291

E09.3292

E09.3293

E09.3299

E09.3311

E09.3312

E09.3313

E09.3319

E09.3391

E09.3392

E09.3393

E09.3399

E09.3411

E09.3412

E09.3413

E09.3419

E09.3491

E09.3492

E09.3493

E09.3499

E09.3511

E09.3512

E09.3513

E09.3519

E09.3591

E09.3592

E09.3593

E09.3599

E09.37X1

E09.37X2

E09.37X3

E09.37X9

E10.311

E10.319

E10.3211

E10.3212

E10.3213

E10.3219

E10.3291

E10.3292

E10.3293

E10.3299

E10.3311

E10.3312

E10.3313

E10.3319

E10.3391

E10.3392

E10.3393

E10.3399

E10.3411

E10.3412

E10.3413

E10.3419

E10.3491

E10.3492

E10.3493

E10.3499

E10.3511

E10.3512

E10.3513

E10.3519

E10.3591

E10.3592

E10.3593

E10.3599

E10.37X1

E10.37X2

E10.37X3

E10.37X9

E11.311

E11.319

E11.3211

E11.3212

E11.3213

E11.3219

E11.3291

E11.3292

E11.3293

E11.3299

E11.3311

E11.3312

E11.3313

E11.3319

E11.3391

E11.3392

E11.3393

E11.3399

E11.3411

E11.3412

E11.3413

E11.3419

E11.3491

E11.3492

E11.3493

E11.3499

E11.3511

E11.3512

E11.3513

E11.3519

E11.3551

E11.3552

E11.3553

E11.3559

E11.3591

E11.3592

E11.3593

E11.3599

E11.37X1

E11.37X2

E11.37X3

E11.37X9

E13.311

E13.319

E13.3211

E13.3212

E13.3213

E13.3219

E13.3291

E13.3292

E13.3293

E13.3299

E13.3311

E13.3312

E13.3313

E13.3319

E13.3391

E13.3392

E13.3393

E13.3399

E13.3411

E13.3412

E13.3413

E13.3419

E13.3491

E13.3492

E13.3493

E13.3499

E13.3511

E13.3512

E13.3513

E13.3519

E13.3591

E13.3592

E13.3593

E13.3599

E13.37X1

E13.37X2

E13.37X3

E13.37X9

H34.8110

H34.8120

H34.8130

H34.8190

H34.8310

H34.8320

H34.8330

H34.8390

H35.3210

H35.3211

H35.3212

H35.3213

H35.3220

H35.3221

H35.3222

H35.3223

H35.3230

H35.3231

H35.3232

H35.3233

H35.3290

H35.3291

H35.3292

H35.3293

Covered Diagnosis codes for Procedure Code J2781

H35.3113

H35.3114

H35.3123

H35.3124

H35.3133

H35.3134

Covered Diagnosis Codes for Procedure Code J2782

H35.3110

H35.3111

H35.3112

H35.3113

H35.3114

H35.3120

H35.3121

H35.3122

H35.3123

H35.3124

H35.3130

H35.3131

H35.3132

H35.3133

H35.3134

H35.3190

H35.3191

H35.3192

H35.3193

H35.3194

Covered Diagnosis Codes for Procedure Code J0177

E08.311

E08.319

E08.3211

E08.3212

E08.3213

E08.3219

E08.3291

E08.3292

E08.3293

E08.3299

E08.3311

E08.3312

E08.3313

E08.3319

E08.3391

E08.3392

E08.3393

E08.3399

E08.3411

E08.3412

E08.3413

E08.3419

E08.3491

E08.3492

E08.3493

E08.3499

E08.3511

E08.3512

E08.3513

E08.3519

E08.3591

E08.3592

E08.3593

E08.3599

E08.37X1

E08.37X2

E08.37X3

E08.37X9

E09.311

E09.319

E09.3211

E09.3212

E09.3213

E09.3219

E09.3291

E09.3292

E09.3293

E09.3299

E09.3311

E09.3312

E09.3313

E09.3319

E09.3391

E09.3392

E09.3393

E09.3399

E09.3411

E09.3412

E09.3413

E09.3419

E09.3491

E09.3492

E09.3493

E09.3499

E09.3511

E09.3512

E09.3513

E09.3519

E09.3591

E09.3592

E09.3593

E09.3599

E09.37X1

E09.37X2

E09.37X3

E09.37X9

E10.311

E10.319

E10.3211

E10.3212

E10.3213

E10.3219

E10.3291

E10.3292

E10.3293

E10.3299

E10.3311

E10.3312

E10.3313

E10.3319

E10.3391

E10.3392

E10.3393

E10.3399

E10.3411

E10.3412

E10.3413

E10.3419

E10.3491

E10.3492

E10.3493

E10.3499

E10.3511

E10.3512

E10.3513

E10.3519

E10.3591

E10.3592

E10.3593

E10.3599

E10.37X1

E10.37X2

E10.37X3

E10.37X9

E11.311

E11.319

E11.3211

E11.3212

E11.3213

E11.3219

E11.3291

E11.3292

E11.3293

E11.3299

E11.3311

E11.3312

E11.3313

E11.3319

E11.3391

E11.3392

E11.3393

E11.3399

E11.3411

E11.3412

E11.3413

E11.3419

E11.3491

E11.3492

E11.3493

E11.3499

E11.3511

E11.3512

E11.3513

E11.3519

E11.3551

E11.3552

E11.3553

E11.3559

E11.3591

E11.3592

E11.3593

E11.3599

E11.37X1

E11.37X2

E11.37X3

E11.37X9

E13.311

E13.319

E13.3211

E13.3212

E13.3213

E13.3219

E13.3291

E13.3292

E13.3293

E13.3299

E13.3311

E13.3312

E13.3313

E13.3319

E13.3391

E13.3392

E13.3393

E13.3399

E13.3411

E13.3412

E13.3413

E13.3419

E13.3491

E13.3492

E13.3493

E13.3499

E13.3511

E13.3512

E13.3513

E13.3519

E13.3591

E13.3592

E13.3593

E13.3599

E13.37X1

E13.37X2

E13.37X3

E13.37X9

H35.3210

H35.3211

H35.3212

H35.3213

H35.3220

H35.3221

H35.3222

H35.3223

H35.3230

H35.3231

H35.3232

H35.3233

H35.3290

H35.3291

H35.3292

H35.3293

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 7-21-2022 - Effective August 29, 2022

Adopted new policy

Internal Medical Policy Committee 9-28-2022 - Effective October 01, 2022

Added new code, J2777, for faricimab-svoa (Vabysmo) to the policy and
Removed C9097

Internal Medical Policy Committee 11-29-2022 - Effective December 19, 2022

Added new drug ranibizumab-eqrn (Cimerli), to the policy
Updated all diagnosis codes using current reference
Updated experimental/investigational statement

Internal Medical Policy Committee 3-23-2023 Effective April 01, 2023

Added new code, Q5128 ranibizumab-eqrn (Cimerli), to the policy

Internal Medical Policy Committee 5-23-2023 - Effective July 03, 2023

Added new drug, pegcetacoplan (Syfovre), C9151, to the policy
Removed procedure codes J7316 and J2503 as these are obsolete products

Internal Medical Policy Committee 9-12-2023 Effective October 09, 2023

Added new code, J2781 for pegcetacoplan injection (Syfovre), to the policy
Removed code, C9151 for pegcetacoplan injection (Syfovre), from the policy
Updated diagnosis code list for J0178, J0179, J2777, J2778/Q5128 and J2781

Internal Medical Policy Committee 11-15-2023 Effective January 01, 2024

Updated description
Added aflibercept (Eylea HD) to the policy
Added avacincaptad pegol (Izervay) to the policy

Internal Medical Policy Committee 1-16-2024 Effective March 04, 2024

Added diagnosis macular edema following RVO for faricimab-svoa (Vabysmo), J2777 and applicable diagnosis codes

Internal Medical Policy Committee 3-19-2024 Effective April 01, 2024

Added diagnosis code H35.3293 for J0179; and
Added diagnosis codes H35.101; H35.102; H35.103; H35.109; H35.141; H35.142; H35.143; H35.149; H35.151; H35.152; H35.153; H35.159; H35.161; H35.162; H35.163; and H35.169 for J0178; and
Added diagnosis code E08.3291 for J2778; and Q5128; and
Added new code J0177 for aflibercept (Eylea HD); and
Removed code C9161 for aflibercept (Eylea HD); and
Added new code, J2782 for avacincaptad pegol (Izervay); and
Removed code C9162 for avacincaptad pegol (Izervay).

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: I-94-046

Section: Injections

Effective Date: August 29, 2022

Revised Date: January 11, 2024

Revision Effective Date: March 04, 2024

Last Reviewed: January 16, 2024

Archived Date: March 31, 2024

Applies To: Commercial and Medicaid Expansion

Description

Vascular endothelial growth factor (VEGF) has been implicated in the pathogenesis of a variety of ocular vascular conditions. The macula, with the fovea at its center, has the highest photoreceptor concentration and is where visual detail is discerned. The anti-VEGF agent's brolucizumab-dbll (Beovu®), ranibizumab (Lucentis™), ranibizumab-eqrn (Cimerli^TM), ranibizumab-nuna (Byooviz^TM), ranibizumab injection ocular implant (Susvimo^TM), bevacizumab (Avastin®), aflibercept (Eylea ™ and Eylea HD®), and faricimab-svoa (Vabysmo^TM) are used to treat certain ocular disorders and are given by intravitreal injection.

Geographic atrophy (GA) is a late stage of dry age-related macular degeneration (AMD). Pegcetacoplan (Syfovre^TM) and (avacincaptad pegol (Izervay^TM) are intravitreal injections for the treatment of GA that works by slowing progression of GA lesions that can permanently damage the macula.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

Aflibercept (Eylea) may be considered medically necessary for the treatment of individuals with ANY ONE of the following conditions:

Diabetic macular edema (DME); or
Diabetic retinopathy in patients with r without DME; or
Macular edema following retinal vein occlusion (RVO); or
Retinopathy of prematurity; or
Neovascular (wet) age-related macular degeneration (AMD).

Reauthorization Criteria

Continuation of aflibercept (Eylea) may be considered medically necessary when there is positive clinical response (e.g., improvement in visual acuity).

Procedure Code

J0178

Aflibercept (Eylea HD) may be considered medically necessary for the treatment of individuals with ANY ONE of the following conditions:

Diabetic Macular Edema (DME); or
Diabetic Retinopathy (DR); or
Neovascular (wet) AMD.

Reauthorization Criteria

Continuation of aflibercept (Eylea) may be considered medically necessary when there is positive clinical response (e.g. improvement in visual acuity),

Procedure Codes

C9161

J3590

Brolucizumab-dbll (Beovu) may be considered medically necessary for the treatment of individuals with:

Neovascular (wet) AMD.

Reauthorization Criteria

Continuation of brolucizumab-dbll (Beovu) may be considered medically necessary when there is positive clinical response (e.g., improvement in visual acuity).

Procedure Code

J0179

Ranibizumab (Lucentis) or ranibizumab-eqrn (Cimerli) may be considered medically necessary for the treatment of individuals with ANY ONE of the following conditions:

Diabetic macular edema (DME); or
Diabetic retinopathy in individuals with or without DME; or
Macular edema following RVO; or
Myopic Choroidal Neovascularization (mCNV); or
Neovascular (wet) AMD.

Reauthorization Criteria

Continuation of ranibizumab (Lucentis) or ranibizumab-eqrn (Cimerli) may be considered medically necessary when there is positive clinical response (e.g., improvement in visual acuity).

Procedure Codes

J2778

Q5128

Ranibizumab-nuna (Byooviz) may be considered medically necessary for the treatment of individuals with ANY ONE of the following conditions:

Macular Edema Following Retinal Vein Occlusion (RVO); or
Myopic Choroidal Neovascularization; or
Neovascular (Wet) Age-Related Macular Degeneration.

Reauthorization Criteria

Continuation of ranibizumab-nuna (Byooviz) may be considered medically necessary when there is positive clinical response (e.g., improvement in visual acuity).

Procedure Code

Q5124

Ranibizumab (Susvimo) intravitreal injection via ocular implant may be considered medically necessary for the treatment of individuals with:

Neovascular (wet) Age-related Macular Degeneration (AMD)

Reauthorization Criteria

Continuation of ranibizumab (Susvimo) may be considered medically necessary when there is positive clinical response (e.g., improvement in visual acuity).

Procedure Code

J2779

Faricimab-svoa (Vabysmo) may be considered medically necessary for the treatment of individuals with ANY ONE of the following conditions:

Neovascular (Wet) (AMD); or
Diabetic Macular Edema (DME); or
Macular edema following RVO.

Reauthorization Criteria

Continuation of faricimab-svoa (Vabysmo) may be considered medically necessary when there is positive clinical response (e.g., improvement in visual acuity).

Procedure Code

J2777

Pegcetacoplan injection (Syfovre) may be considered medically necessary for the treatment of individuals with the following condition:

Geographic atrophy (GA) secondary to age-related macular degeneration (AMD).

Reauthorization Criteria

Continuation of pegcetacoplan injection (Syfovre) may be considered medically necessary when there is positive clinical response (e.g., reduction in rate of GA lesion growth documented by difference in mm²).

Procedure Code

J2781

Avacincaptad pegol intravitreal solution (Izervay) may be considered medically necessary for the treatment of individuals with the following condition:

Geographic atrophy (GA) secondary to nonexudative (dry) AMD; and

Reauthorization Criteria

Additional injections of avacincaptad pegol (Izervay) after the initial 12 months are considered experimental/investigational, and therefore, non-covered. Scientific evidence does not support use beyond 12 months.

Procedure Codes

C9162

J3590

Diagnosis Codes

Covered Diagnosis Codes for Procedure Code J0179

E08.311

E08.3211

E08.3212

E08.3213

E08.3219

E08.3311

E08.3312

E08.3313

E08.3319

E08.3411

E08.3412

E08.3413

E08.3419

E08.3511

E08.3512

E08.3513

E08.3519

E09.311

E09.3211

E09.3212

E09.3213

E09.3219

E09.3311

E09.3312

E09.3313

E09.3319

E09.3411

E09.3412

E09.3413

E09.3419

E09.3511

E09.3512

E09.3513

E09.3519

E10.311

E10.319

E10.3211

E10.3212

E10.3213

E10.3219

E10.3291

E10.3292

E10.3293

E10.3299

E10.3311

E10.3312

E10.3313

E10.3319

E10.3411

E10.3412

E10.3413

E10.3419

E10.3511

E10.3512

E10.3513

E10.3519

E11.311

E11.319

E11.3211

E11.3212

E11.3213

E11.3219

E11.3311

E11.3312

E11.3313

E11.3319

E11.3411

E11.3412

E11.3413

E11.3419

E11.3511

E11.3512

E11.3513

E11.3519

E13.311

E13.3211

E13.3212

E13.3213

E13.3219

E13.3311

E13.3312

E13.3313

E13.3319

E13.3411

E13.3412

E13.3413

E13.3419

E13.3511

E13.3512

E13.3513

E13.3519

H35.3210

H35.3211

H35.3212

H35.3213

H35.3220

H35.3221

H35.3222

H35.3223

H35.3230

H35.3231

H35.3232

H35.3233

H35.3290

H35.3291

H35.3292

Covered Diagnosis Codes for Procedure Code J2779

H35.3210

H35.3211

H35.3212

H35.3213

H35.3220

H35.3221

H35.3222

H35.3223

H35.3230

H35.3231

H35.3232

H35.3233

H35.3290

H35.3291

H35.3292

H35.3293

Covered Diagnosis Codes for Procedure Code J0178

E08.311

E08.319

E08.3211

E08.3212

E08.3213

E08.3219

E08.3291

E08.3292

E08.3293

E08.3299

E08.3311

E08.3312

E08.3313

E08.3319

E08.3391

E08.3392

E08.3393

E08.3399

E08.3411

E08.3412

E08.3413

E08.3419

E08.3491

E08.3492

E08.3493

E08.3499

E08.3511

E08.3512

E08.3513

E08.3519

E08.3521

E08.3522

E08.3523

E08.3529

E08.3531

E08.3532

E08.3533

E08.3539

E08.3541

E08.3542

E08.3543

E08.3549

E08.3551

E08.3552

E08.3553

E08.3559

E08.3591

E08.3592

E08.3593

E08.3599

E09.311

E09.319

E09.3211

E09.3212

E09.3213

E09.3219

E09.3291

E09.3292

E09.3293

E09.3299

E09.3311

E09.3312

E09.3313

E09.3319

E09.3391

E09.3392

E09.3393

E09.3399

E09.3411

E09.3412

E09.3413

E09.3419

E09.3491

E09.3492

E09.3493

E09.3499

E09.3511

E09.3512

E09.3513

E09.3519

E09.3521

E09.3522

E09.3523

E09.3529

E09.3531

E09.3532

E09.3533

E09.3539

E09.3541

E09.3542

E09.3543

E09.3549

E09.3551

E09.3552

E09.3553

E09.3559

E09.3591

E09.3592

E09.3593

E09.3599

E10.311

E10.319

E10.3211

E10.3212

E10.3213

E10.3219

E10.3291

E10.3292

E10.3293

E10.3299

E10.3311

E10.3312

E10.3313

E10.3319

E10.3391

E10.3392

E10.3393

E10.3399

E10.3411

E10.3412

E10.3413

E10.3419

E10.3491

E10.3492

E10.3493

E10.3499

E10.3511

E10.3512

E10.3513

E10.3519

E10.3521

E10.3522

E10.3523

E10.3529

E10.3531

E10.3532

E10.3533

E10.3539

E10.3541

E10.3542

E10.3543

E10.3549

E10.3551

E10.3552

E10.3553

E10.3559

E10.3591

E10.3592

E10.3593

E10.3599

E11.311

E11.319

E11.3211

E11.3212

E11.3213

E11.3219

E11.3291

E11.3292

E11.3293

E11.3299

E11.3311

E11.3312

E11.3313

E11.3319

E11.3391

E11.3392

E11.3393

E11.3399

E11.3411

E11.3412

E11.3413

E11.3419

E11.3491

E11.3492

E11.3493

E11.3499

E11.3511

E11.3512

E11.3513

E11.3519

E11.3521

E11.3522

E11.3523

E11.3529

E11.3531

E11.3532

E11.3533

E11.3539

E11.3541

E11.3542

E11.3543

E11.3549

E11.3551

E11.3552

E11.3553

E11.3559

E11.3591

E11.3592

E11.3593

E11.3599

E13.311

E13.319

E13.3211

E13.3212

E13.3213

E13.3219

E13.3291

E13.3292

E13.3293

E13.3299

E13.3311

E13.3312

E13.3313

E13.3319

E13.3391

E13.3392

E13.3393

E13.3399

E13.3411

E13.3412

E13.3413

E13.3419

E13.3491

E13.3492

E13.3493

E13.3499

E13.3511

E13.3512

E13.3513

E13.3519

E13.3521

E13.3522

E13.3523

E13.3529

E13.3531

E13.3532

E13.3533

E13.3539

E13.3541

E13.3542

E13.3543

E13.3549

E13.3551

E13.3552

E13.3553

E13.3559

E13.3591

E13.3592

E13.3593

E13.3599

H34.8110

H34.8120

H34.8130

H34.8190

H34.8310

H34.8320

H34.8330

H34.8390

H35.3210

H35.3211

H35.3212

H35.3213

H35.3220

H35.3221

H35.3222

H35.3223

H35.3230

H35.3231

H35.3232

H35.3233

H35.3290

H35.3291

H35.3292

H35.3293

Covered Diagnosis Codes for Procedure Codes J2778, Q5128

E08.311

E08.319

E08.3191

E08.3211

E08.3212

E08.3213

E08.3219

E08.3292

E08.3293

E08.3299

E08.3311

E08.3312

E08.3313

E08.3319

E08.3391

E08.3392

E08.3393

E08.3399

E08.3411

E08.3412

E08.3413

E08.3419

E08.3491

E08.3492

E08.3493

E08.3499

E08.3511

E08.3512

E08.3513

E08.3519

E08.3521

E08.3522

E08.3523

E08.3529

E08.3531

E08.3532

E08.3533

E08.3539

E08.3541

E08.3542

E08.3543

E08.3549

E08.3551

E08.3552

E08.3553

E08.3559

E08.3591

E08.3592

E08.3593

E08.3599

E09.311

E09.319

E09.3211

E09.3212

E09.3213

E09.3219

E09.3291

E09.3292

E09.3293

E09.3299

E09.3311

E09.3312

E09.3313

E09.3319

E09.3391

E09.3392

E09.3393

E09.3399

E09.3411

E09.3412

E09.3413

E09.3419

E09.3491

E09.3492

E09.3493

E09.3499

E09.3511

E09.3512

E09.3513

E09.3519

E10.311

E10.3211

E10.3212

E10.3213

E10.3219

E10.3311

E10.3312

E10.3313

E09.3521

E09.3522

E09.3523

E09.3529

E09.3531

E09.3532

E09.3533

E09.3539

E09.3541

E09.3542

E09.3543

E09.3549

E09.3551

E09.3552

E09.3553

E09.3559

E09.3591

E09.3592

E09.3593

E09.3599

E10.319

E10.3291

E10.3292

E10.3293

E10.3299

E10.3319

E10.3391

E10.3392

E10.3393

E10.3399

E10.3411

E10.3412

E10.3413

E10.3419

E10.3491

E10.3492

E10.3493

E10.3499

E10.3511

E10.3512

E10.3513

E10.3519

E10.3521

E10.3522

E10.3523

E10.3529

E10.3531

E10.3532

E10.3533

E10.3539

E10.3541

E10.3542

E10.3543

E10.3549

E10.3551

E10.3552

E10.3553

E10.3559

E10.3591

E10.3592

E10.3593

E10.3599

E11.311

E11.319

E11.3211

E11.3212

E11.3213

E11.3219

E11.3291

E11.3292

E11.3293

E11.3299

E11.3311

E11.3312

E11.3313

E11.3319

E11.3391

E11.3392

E11.3393

E11.3399

E11.3411

E11.3412

E11.3413

E11.3419

E11.3491

E11.3492

E11.3493

E11.3499

E11.3511

E11.3512

E11.3513

E11.3519

E11.3521

E11.3522

E11.3523

E11.3529

E11.3531

E11.3532

E11.3533

E11.3539

E11.3541

E11.3542

E11.3543

E11.3549

E11.3551

E11.3552

E11.3553

E11.3559

E11.3591

E11.3592

E11.3593

E11.3599

E13.311

E13.319

E13.3211

E13.3212

E13.3213

E13.3219

E13.3291

E13.3292

E13.3293

E13.3299

E13.3311

E13.3312

E13.3313

E13.3319

E13.3391

E13.3392

E13.3393

E13.3399

E13.3411

E13.3412

E13.3413

E13.3419

E13.3491

E13.3492

E13.3493

E13.3499

E13.3511

E13.3512

E13.3513

E13.3519

E13.3521

E13.3522

E13.3523

E13.3529

E13.3531

E13.3532

E13.3533

E13.3539

E13.3541

E13.3542

E13.3543

E13.3549

E13.3551

E13.3552

E13.3553

E13.3559

E13.3591

E13.3592

E13.3593

E13.3599

H34.8110

H34.8120

H34.8130

H34.8190

H34.8310

H34.8320

H34.8330

H34.8390

H35.051

H35.052

H35.053

H35.059

H35.3210

H35.3211

H35.3212

H35.3213

H35.3220

H35.3221

H35.3222

H35.3223

H35.3230

H35.3231

H35.3232

H35.3233

H35.3290

H35.3291

H35.3292

H35.3293

H35.81

H44.2A1

H44.2A2

H44.2A3

H44.2A9

Covered Diagnosis Codes for Procedure Code Q5124

H34.8110

H34.8111

H34.8112

H34.8120

H34.8121

H34.8122

H34.8130

H34.8131

H34.8132

H34.8190

H34.8191

H34.8192

H34.8310

H34.8311

H34.8312

H34.8320

H34.8321

H34.8322

H34.8330

H34.8390

H35.3210

H35.3211

H35.3212

H35.3213

H35.3220

H35.3221

H35.3222

H35.3223

H35.3230

H35.3231

H35.3232

H35.3233

H35.3290

H35.3291

H35.3292

H35.3293

H44.2A1

H44.2A2

H44.2A3

H44.2A9

Covered Diagnosis Codes for Procedure Code J2777

E08.311

E08.319

E08.3211

E08.3212

E08.3213

E08.3219

E08.3291

E08.3292

E08.3293

E08.3299

E08.3311

E08.3312

E08.3313

E08.3319

E08.3391

E08.3392

E08.3393

E08.3399

E08.3411

E08.3412

E08.3413

E08.3419

E08.3491

E08.3492

E08.3493

E08.3499

E08.3511

E08.3512

E08.3513

E08.3519

E08.3591

E08.3592

E08.3593

E08.3599

E08.37X1

E08.37X2

E08.37X3

E08.37X9

E09.311

E09.319

E09.3211

E09.3212

E09.3213

E09.3219

E09.3291

E09.3292

E09.3293

E09.3299

E09.3311

E09.3312

E09.3313

E09.3319

E09.3391

E09.3392

E09.3393

E09.3399

E09.3411

E09.3412

E09.3413

E09.3419

E09.3491

E09.3492

E09.3493

E09.3499

E09.3511

E09.3512

E09.3513

E09.3519

E09.3591

E09.3592

E09.3593

E09.3599

E09.37X1

E09.37X2

E09.37X3

E09.37X9

E10.311

E10.319

E10.3211

E10.3212

E10.3213

E10.3219

E10.3291

E10.3292

E10.3293

E10.3299

E10.3311

E10.3312

E10.3313

E10.3319

E10.3391

E10.3392

E10.3393

E10.3399

E10.3411

E10.3412

E10.3413

E10.3419

E10.3491

E10.3492

E10.3493

E10.3499

E10.3511

E10.3512

E10.3513

E10.3519

E10.3591

E10.3592

E10.3593

E10.3599

E10.37X1

E10.37X2

E10.37X3

E10.37X9

E11.311

E11.319

E11.3211

E11.3212

E11.3213

E11.3219

E11.3291

E11.3292

E11.3293

E11.3299

E11.3311

E11.3312

E11.3313

E11.3319

E11.3391

E11.3392

E11.3393

E11.3399

E11.3411

E11.3412

E11.3413

E11.3419

E11.3491

E11.3492

E11.3493

E11.3499

E11.3511

E11.3512

E11.3513

E11.3519

E11.3551

E11.3552

E11.3553

E11.3559

E11.3591

E11.3592

E11.3593

E11.3599

E11.37X1

E11.37X2

E11.37X3

E11.37X9

E13.311

E13.319

E13.3211

E13.3212

E13.3213

E13.3219

E13.3291

E13.3292

E13.3293

E13.3299

E13.3311

E13.3312

E13.3313

E13.3319

E13.3391

E13.3392

E13.3393

E13.3399

E13.3411

E13.3412

E13.3413

E13.3419

E13.3491

E13.3492

E13.3493

E13.3499

E13.3511

E13.3512

E13.3513

E13.3519

E13.3591

E13.3592

E13.3593

E13.3599

E13.37X1

E13.37X2

E13.37X3

E13.37X9

H34.8110

H34.8120

H34.8130

H34.8190

H34.8310

H34.8320

H34.8330

H34.8390

H35.3210

H35.3211

H35.3212

H35.3213

H35.3220

H35.3221

H35.3222

H35.3223

H35.3230

H35.3231

H35.3232

H35.3233

H35.3290

H35.3291

H35.3292

H35.3293

Covered Diagnosis codes for Procedure Code J2781

H35.3113

H35.3114

H35.3123

H35.3124

H35.3133

H35.3134

Covered Diagnosis Codes for Procedure Code C9162

H35.3110

H35.3111

H35.3112

H35.3113

H35.3114

H35.3120

H35.3121

H35.3122

H35.3123

H35.3124

H35.3130

H35.3131

H35.3132

H35.3133

H35.3134

H35.3190

H35.3191

H35.3192

H35.3193

H35.3194

Covered Diagnosis Codes for Procedure Code C9161

E08.311

E08.319

E08.3211

E08.3212

E08.3213

E08.3219

E08.3291

E08.3292

E08.3293

E08.3299

E08.3311

E08.3312

E08.3313

E08.3319

E08.3391

E08.3392

E08.3393

E08.3399

E08.3411

E08.3412

E08.3413

E08.3419

E08.3491

E08.3492

E08.3493

E08.3499

E08.3511

E08.3512

E08.3513

E08.3519

E08.3591

E08.3592

E08.3593

E08.3599

E08.37X1

E08.37X2

E08.37X3

E08.37X9

E09.311

E09.319

E09.3211

E09.3212

E09.3213

E09.3219

E09.3291

E09.3292

E09.3293

E09.3299

E09.3311

E09.3312

E09.3313

E09.3319

E09.3391

E09.3392

E09.3393

E09.3399

E09.3411

E09.3412

E09.3413

E09.3419

E09.3491

E09.3492

E09.3493

E09.3499

E09.3511

E09.3512

E09.3513

E09.3519

E09.3591

E09.3592

E09.3593

E09.3599

E09.37X1

E09.37X2

E09.37X3

E09.37X9

E10.311

E10.319

E10.3211

E10.3212

E10.3213

E10.3219

E10.3291

E10.3292

E10.3293

E10.3299

E10.3311

E10.3312

E10.3313

E10.3319

E10.3391

E10.3392

E10.3393

E10.3399

E10.3411

E10.3412

E10.3413

E10.3419

E10.3491

E10.3492

E10.3493

E10.3499

E10.3511

E10.3512

E10.3513

E10.3519

E10.3591

E10.3592

E10.3593

E10.3599

E10.37X1

E10.37X2

E10.37X3

E10.37X9

E11.311

E11.319

E11.3211

E11.3212

E11.3213

E11.3219

E11.3291

E11.3292

E11.3293

E11.3299

E11.3311

E11.3312

E11.3313

E11.3319

E11.3391

E11.3392

E11.3393

E11.3399

E11.3411

E11.3412

E11.3413

E11.3419

E11.3491

E11.3492

E11.3493

E11.3499

E11.3511

E11.3512

E11.3513

E11.3519

E11.3551

E11.3552

E11.3553

E11.3559

E11.3591

E11.3592

E11.3593

E11.3599

E11.37X1

E11.37X2

E11.37X3

E11.37X9

E13.311

E13.319

E13.3211

E13.3212

E13.3213

E13.3219

E13.3291

E13.3292

E13.3293

E13.3299

E13.3311

E13.3312

E13.3313

E13.3319

E13.3391

E13.3392

E13.3393

E13.3399

E13.3411

E13.3412

E13.3413

E13.3419

E13.3491

E13.3492

E13.3493

E13.3499

E13.3511

E13.3512

E13.3513

E13.3519

E13.3591

E13.3592

E13.3593

E13.3599

E13.37X1

E13.37X2

E13.37X3

E13.37X9

H35.3210

H35.3211

H35.3212

H35.3213

H35.3220

H35.3221

H35.3222

H35.3223

H35.3230

H35.3231

H35.3232

H35.3233

H35.3290

H35.3291

H35.3292

H35.3293

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 7-21-2022 - Effective August 29, 2022

Adopted new policy

Internal Medical Policy Committee 9-28-2022 - Effective October 01, 2022

Added new code, J2777, for faricimab-svoa (Vabysmo) to the policy and
Removed C9097

Internal Medical Policy Committee 11-29-2022 - Effective December 19, 2022

Added new drug ranibizumab-eqrn (Cimerli), to the policy
Updated all diagnosis codes using current reference
Updated experimental/investigational statement

Internal Medical Policy Committee 3-23-2023 Effective April 01, 2023

Added new code, Q5128 ranibizumab-eqrn (Cimerli), to the policy

Internal Medical Policy Committee 5-23-2023 - Effective July 03, 2023

Added new drug, pegcetacoplan (Syfovre), C9151, to the policy
Removed procedure codes J7316 and J2503 as these are obsolete products

Internal Medical Policy Committee 9-12-2023 Effective October 09, 2023

Added new code, J2781 for pegcetacoplan injection (Syfovre), to the policy
Removed code, C9151 for pegcetacoplan injection (Syfovre), from the policy
Updated diagnosis code list for J0178, J0179, J2777, J2778/Q5128 and J2781

Internal Medical Policy Committee 11-15-2023 Effective January 01, 2024

Updated description
Added aflibercept (Eylea HD) to the policy
Added avacincaptad pegol (Izervay) to the policy

Internal Medical Policy Committee 1-16-2024 Effective March 04, 2024

Added diagnosis macular edema following RVO for faricimab-svoa (Vabysmo), J2777 and applicable diagnosis codes

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Intravitreal Injections

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