Aetna Vascular Endothelial Growth Factor Inhibitors for Ocular Indications coverage criteria

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

Coverage criteria

• SCOPE: This Clinical Policy Bulletin addresses vascular endothelial growth factor (VEGF) inhibitors for ocular indications for commercial medical plans.
• AFLIBERCEPT [(Eylea), (Eylea HD)], aflibercept-abzv (Enzeevu), aflibercept-ayyh (Pavblu), aflibercept-boav (Eydenzelt), aflibercept-jbvf (Yesafili), aflibercept-mrbb (Ahzantive), or aflibercept-yszy (Opuviz) injection — Criteria for Initial Approval: medically necessary for the treatment of the following indications (ONE of): Diabetic macular edema; Diabetic retinopathy; Macular edema following retinal vein occlusion; Neovascular (wet) age-related macular degeneration (AMD); Retinopathy of prematurity (Eylea and biosimilars [Ahzantive, Enzeevu, Eydenzelt, Opuviz, Pavblu, Yesafili] only).
• AFLIBERCEPT [(Eylea) or (Eylea HD)], aflibercept-abzv (Enzeevu), aflibercept-ayyh (Pavblu), aflibercept-boav (Eydenzelt), aflibercept-jbvf (Yesafili), aflibercept-mrbb (Ahzantive), or aflibercept-yszy (Opuviz) — Continuation of Therapy: medically necessary in members requesting reauthorization for an indication listed in the Criteria for Initial Approval section when the member has demonstrated a positive clinical response to therapy (e.g., improvement or maintenance in best corrected visual acuity [BCVA] or visual field, or a reduction in the rate of vision decline or the risk of more severe vision loss).
• INTRAVITREAL BEVACIZUMAB (Avastin), bevacizumab-adcd (Vegzelma), bevacizumab-awwb (Mvasi), bevacizumab-bvzr (Zirabev), bevacizumab-maly (Alymsys), bevacizumab-nwgd (Jobevne), or bevacizumab-tnjn (Avzivi) injections — Criteria for Initial Approval: medically necessary for treatment of the following retinal disorders (ONE of): Diabetic macular edema; Neovascular (wet) age-related macular degeneration; Macular edema following retinal vein occlusion; Proliferative diabetic retinopathy; Choroidal neovascularization (including myopic choroidal neovascularization, angioid streaks, choroiditis [including choroiditis secondary to ocular histoplasmosis], idiopathic degenerative myopia, retinal dystrophies, rubeosis iridis, pseudoxanthoma elasticum, and trauma); Neovascular glaucoma; Retinopathy of prematurity; Polypoidal choroidal vasculopathy.
• BEVACIZUMAB (Avastin, Alymsys, Avzivi, Mvasi, Jobevne, Vegzelma, or Zirabev) — Continuation of Therapy: medically necessary for an indication outlined in the Criteria for Initial Approval section when the member has demonstrated a positive clinical response to therapy (e.g., improvement or maintenance in best corrected visual acuity [BCVA] or visual field, or a reduction in the rate of vision decline or the risk of more severe vision loss).
• BROLUCIZUMAB-DBLL intravitreal injection (Beovu) — Criteria for Initial Approval: medically necessary for treatment of neovascular (wet) age-related macular degeneration.
• BROLUCIZUMAB-DBLL intravitreal injection (Beovu) — Criteria for Initial Approval: medically necessary for treatment of diabetic macular edema.
• BROLUCIZUMAB-DBLL (Beovu) — Continuation of Therapy: medically necessary for members requesting reauthorization for an indication listed in the Criteria for Initial Approval section when the member has demonstrated a positive clinical response to therapy (e.g., improvement or maintenance in BCVA or visual field, or a reduction in the rate of vision decline or the risk of more severe vision loss).
• FARICIMAB-SVOA injection (Vabysmo) — Criteria for Initial Approval: medically necessary for treatment of diabetic macular edema.
• FARICIMAB-SVOA injection (Vabysmo) — Criteria for Initial Approval: medically necessary for treatment of neovascular (wet) age-related macular degeneration.
• FARICIMAB-SVOA injection (Vabysmo) — Criteria for Initial Approval: medically necessary for treatment of macular edema following retinal vein occlusion.
• FARICIMAB-SVOA injection (Vabysmo) — Continuation of Therapy: medically necessary in members requesting reauthorization for an indication listed in the Criteria for Initial Approval section when the member has demonstrated a positive clinical response to therapy (e.g., improvement or maintenance in BCVA or visual field, or a reduction in the rate of vision decline or the risk of more severe vision loss).
• INTRAVITREAL RANIBIZUMAB (Lucentis), ranibizumab-eqrn (Cimerli), or ranibizumab-nuna (Byooviz) — Criteria for Initial Approval: medically necessary for the treatment of the following indications (ONE of): Diabetic macular edema; Diabetic retinopathy; Macular edema following retinal vein occlusion; Myopic choroidal neovascularization; Neovascular (wet) age-related macular degeneration (AMD).
• INTRAVITREAL RANIBIZUMAB (Lucentis), ranibizumab-eqrn (Cimerli), or ranibizumab-nuna (Byooviz) — Continuation of Therapy: medically necessary in members requesting reauthorization for an indication listed in the Criteria for Initial Approval section when the member has demonstrated a positive clinical response to therapy (e.g., improvement or maintenance in BCVA or visual field, or a reduction in the rate of vision decline or the risk of more severe vision loss).
• RANIBIZUMAB injection (Susvimo) for Neovascular (wet) AMD — Criteria for Initial Approval: medically necessary when ALL of the following are met: (1) Member has a diagnosis of neovascular (wet) age-related macular degeneration; AND (2) Member has previously responded to at least two intravitreal injections of a VEGF inhibitor (e.g., Avastin, Eylea) within the past 6 months; AND (3) Must be used in conjunction with the Susvimo ocular implant.
• RANIBIZUMAB injection (Susvimo) for Diabetic Macular Edema (DME) — Criteria for Initial Approval: medically necessary when ALL of the following are met: (1) Member has a diagnosis of diabetic macular edema; AND (2) Member has previously responded to at least two intravitreal injections of a VEGF inhibitor (e.g., Avastin, Eylea); AND (3) Must be used in conjunction with the Susvimo ocular implant.
• RANIBIZUMAB injection (Susvimo) for Diabetic Retinopathy (DR) — Criteria for Initial Approval: medically necessary when ALL of the following are met: (1) Member has a diagnosis of diabetic retinopathy; AND (2) Member has previously responded to at least two intravitreal injections of a VEGF inhibitor (e.g., Avastin, Eylea); AND (3) Must be used in conjunction with the Susvimo ocular implant.
• RANIBIZUMAB injection (Susvimo) — Continuation of Therapy: medically necessary in members requesting reauthorization for an indication listed in the Criteria for Initial Approval section when the member has demonstrated a positive clinical response to therapy (e.g., improvement or maintenance in BCVA or visual field, or a reduction in the rate of vision decline or the risk of more severe vision loss).
• RANIBIZUMAB (Susvimo) OCULAR IMPLANT — medically necessary when used with intravitreal ranibizumab injection (Susvimo) for treatment of neovascular (wet) age-related macular degeneration, diabetic macular edema, or diabetic retinopathy when criteria are met for intravitreal ranibizumab injection (Susvimo).
• BRAND SELECTION (commercial plans): Per Aetna commercial benefit plans, health care services are considered not medically necessary if more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results; Aetna commercial plans may require a trial of a lower-cost drug (preferred medication) at least as likely to produce equivalent therapeutic results before approving coverage for a higher-cost drug within the same therapeutic class.

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

• 67028·PA verdict·Rate

Documentation required

• Statements of Medical Necessity must be submitted via the applicable Specialty Pharmacy Precertification forms for the precertification-required products.

Frequently asked questions

When does Aetna cover Vascular Endothelial Growth Factor Inhibitors for Ocular Indications (CPT 67028), and what gets it denied?

Aetna covers intravitreal VEGF inhibitors (aflibercept/Eylea, bevacizumab/Avastin, brolucizumab/Beovu, faricimab/Vabysmo, ranibizumab/Lucentis and Susvimo, plus their biosimilars) for specific retinal conditions such as neovascular (wet) AMD, diabetic macular edema, diabetic retinopathy, macular edema after retinal vein occlusion, and (drug-specific) indications like retinopathy of prematurity, choroidal neovascularization, neovascular glaucoma, and myopic CNV; Susvimo additionally requires prior response to at least two VEGF-inhibitor injections and use with the Susvimo ocular implant. Precertification is required for the named products, continuation requires a documented positive clinical response, and use is excluded for endophthalmitis/ocular infections, concurrent dual VEGF inhibitors in the same eye, and a long list of experimental/investigational indications. Coverage criteria include: SCOPE: This Clinical Policy Bulletin addresses vascular endothelial growth factor (VEGF) inhibitors for ocular indications for commercial medical plans.; AFLIBERCEPT [(Eylea), (Eylea HD)], aflibercept-abzv (Enzeevu), aflibercept-ayyh (Pavblu), aflibercept-boav (Eydenzelt), aflibercept-jbvf (Yesafili), aflibercept-mrbb (Ahzantive), or aflibercept-yszy (Opuviz) injection — Criteria for Initial Approval: medically necessary for the treatment of the following indications (ONE of): Diabetic macular edema; Diabetic retinopathy; Macular edema following retinal vein occlusion; Neovascular (wet) age-related macular degeneration (AMD); Retinopathy of prematurity (Eylea and biosimilars [Ahzantive, Enzeevu, Eydenzelt, Opuviz, Pavblu, Yesafili] only).; AFLIBERCEPT [(Eylea) or (Eylea HD)], aflibercept-abzv (Enzeevu), aflibercept-ayyh (Pavblu), aflibercept-boav (Eydenzelt), aflibercept-jbvf (Yesafili), aflibercept-mrbb (Ahzantive), or aflibercept-yszy (Opuviz) — Continuation of Therapy: medically necessary in members requesting reauthorization for an indication listed in the Criteria for Initial Approval section when the member has demonstrated a positive clinical response to therapy (e.g., improvement or maintenance in best corrected visual acuity [BCVA] or visual field, or a reduction in the rate of vision decline or the risk of more severe vision loss).; INTRAVITREAL BEVACIZUMAB (Avastin), bevacizumab-adcd (Vegzelma), bevacizumab-awwb (Mvasi), bevacizumab-bvzr (Zirabev), bevacizumab-maly (Alymsys), bevacizumab-nwgd (Jobevne), or bevacizumab-tnjn (Avzivi) injections — Criteria for Initial Approval: medically necessary for treatment of the following retinal disorders (ONE of): Diabetic macular edema; Neovascular (wet) age-related macular degeneration; Macular edema following retinal vein occlusion; Proliferative diabetic retinopathy; Choroidal neovascularization (including myopic choroidal neovascularization, angioid streaks, choroiditis [including choroiditis secondary to ocular histoplasmosis], idiopathic degenerative myopia, retinal dystrophies, rubeosis iridis, pseudoxanthoma elasticum, and trauma); Neovascular glaucoma; Retinopathy of prematurity; Polypoidal choroidal vasculopathy.; BEVACIZUMAB (Avastin, Alymsys, Avzivi, Mvasi, Jobevne, Vegzelma, or Zirabev) — Continuation of Therapy: medically necessary for an indication outlined in the Criteria for Initial Approval section when the member has demonstrated a positive clinical response to therapy (e.g., improvement or maintenance in best corrected visual acuity [BCVA] or visual field, or a reduction in the rate of vision decline or the risk of more severe vision loss).; BROLUCIZUMAB-DBLL intravitreal injection (Beovu) — Criteria for Initial Approval: medically necessary for treatment of neovascular (wet) age-related macular degeneration.; BROLUCIZUMAB-DBLL intravitreal injection (Beovu) — Criteria for Initial Approval: medically necessary for treatment of diabetic macular edema.; BROLUCIZUMAB-DBLL (Beovu) — Continuation of Therapy: medically necessary for members requesting reauthorization for an indication listed in the Criteria for Initial Approval section when the member has demonstrated a positive clinical response to therapy (e.g., improvement or maintenance in BCVA or visual field, or a reduction in the rate of vision decline or the risk of more severe vision loss).; FARICIMAB-SVOA injection (Vabysmo) — Criteria for Initial Approval: medically necessary for treatment of diabetic macular edema.; FARICIMAB-SVOA injection (Vabysmo) — Criteria for Initial Approval: medically necessary for treatment of neovascular (wet) age-related macular degeneration.; FARICIMAB-SVOA injection (Vabysmo) — Criteria for Initial Approval: medically necessary for treatment of macular edema following retinal vein occlusion.; FARICIMAB-SVOA injection (Vabysmo) — Continuation of Therapy: medically necessary in members requesting reauthorization for an indication listed in the Criteria for Initial Approval section when the member has demonstrated a positive clinical response to therapy (e.g., improvement or maintenance in BCVA or visual field, or a reduction in the rate of vision decline or the risk of more severe vision loss).; INTRAVITREAL RANIBIZUMAB (Lucentis), ranibizumab-eqrn (Cimerli), or ranibizumab-nuna (Byooviz) — Criteria for Initial Approval: medically necessary for the treatment of the following indications (ONE of): Diabetic macular edema; Diabetic retinopathy; Macular edema following retinal vein occlusion; Myopic choroidal neovascularization; Neovascular (wet) age-related macular degeneration (AMD).; INTRAVITREAL RANIBIZUMAB (Lucentis), ranibizumab-eqrn (Cimerli), or ranibizumab-nuna (Byooviz) — Continuation of Therapy: medically necessary in members requesting reauthorization for an indication listed in the Criteria for Initial Approval section when the member has demonstrated a positive clinical response to therapy (e.g., improvement or maintenance in BCVA or visual field, or a reduction in the rate of vision decline or the risk of more severe vision loss).; RANIBIZUMAB injection (Susvimo) for Neovascular (wet) AMD — Criteria for Initial Approval: medically necessary when ALL of the following are met: (1) Member has a diagnosis of neovascular (wet) age-related macular degeneration; AND (2) Member has previously responded to at least two intravitreal injections of a VEGF inhibitor (e.g., Avastin, Eylea) within the past 6 months; AND (3) Must be used in conjunction with the Susvimo ocular implant.; RANIBIZUMAB injection (Susvimo) for Diabetic Macular Edema (DME) — Criteria for Initial Approval: medically necessary when ALL of the following are met: (1) Member has a diagnosis of diabetic macular edema; AND (2) Member has previously responded to at least two intravitreal injections of a VEGF inhibitor (e.g., Avastin, Eylea); AND (3) Must be used in conjunction with the Susvimo ocular implant.; RANIBIZUMAB injection (Susvimo) for Diabetic Retinopathy (DR) — Criteria for Initial Approval: medically necessary when ALL of the following are met: (1) Member has a diagnosis of diabetic retinopathy; AND (2) Member has previously responded to at least two intravitreal injections of a VEGF inhibitor (e.g., Avastin, Eylea); AND (3) Must be used in conjunction with the Susvimo ocular implant.; RANIBIZUMAB injection (Susvimo) — Continuation of Therapy: medically necessary in members requesting reauthorization for an indication listed in the Criteria for Initial Approval section when the member has demonstrated a positive clinical response to therapy (e.g., improvement or maintenance in BCVA or visual field, or a reduction in the rate of vision decline or the risk of more severe vision loss).; RANIBIZUMAB (Susvimo) OCULAR IMPLANT — medically necessary when used with intravitreal ranibizumab injection (Susvimo) for treatment of neovascular (wet) age-related macular degeneration, diabetic macular edema, or diabetic retinopathy when criteria are met for intravitreal ranibizumab injection (Susvimo).; BRAND SELECTION (commercial plans): Per Aetna commercial benefit plans, health care services are considered not medically necessary if more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results; Aetna commercial plans may require a trial of a lower-cost drug (preferred medication) at least as likely to produce equivalent therapeutic results before approving coverage for a higher-cost drug within the same therapeutic class.. Applies to 1 code: 67028. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Prior authorization status is code-specific; this CPB is not an exact authorization source for every covered code. Check the Aetna precertification list or PA lookup for the exact code and plan context. Documentation: Statements of Medical Necessity must be submitted via the applicable Specialty Pharmacy Precertification forms for the precertification-required products. Policy exclusions and limitations: CONTRAINDICATION / NOT MEDICALLY NECESSARY (all VEGF inhibitors): VEGF inhibitors for ocular indications are contraindicated and considered not medically necessary for persons with endophthalmitis or with ocular or periocular infections.; ALL DRUGS: Aetna considers all other indications (not listed in the Criteria for Initial Approval for each respective drug) as not medically necessary; experimental, investigational, or unproven.; AFLIBERCEPT [(Eylea) and (Eylea HD)], aflibercept-abzv (Enzeevu), aflibercept-ayyh (Pavblu), aflibercept-boav (Eydenzelt), aflibercept-jbvf (Yesafili), aflibercept-mrbb (Ahzantive), or aflibercept-yszy (Opuviz) — experimental, investigational, or unproven (effectiveness not established; not an all-inclusive list) for: Central serous chorioretinopathy.; AFLIBERCEPT (and named biosimilars) — experimental, investigational, or unproven for: Choroidal neovascularization due to ocular histoplasmosis.; AFLIBERCEPT (and named biosimilars) — experimental, investigational, or unproven for: Colorectal cancer.; AFLIBERCEPT (and named biosimilars) — experimental, investigational, or unproven for: Cystoid macular edema.; AFLIBERCEPT (and named biosimilars) — experimental, investigational, or unproven for: Myopic choroidal neovascularization.; AFLIBERCEPT (and named biosimilars) — experimental, investigational, or unproven for: Neovascular glaucoma.; AFLIBERCEPT (and named biosimilars) — experimental, investigational, or unproven for: Ovarian cancer.; AFLIBERCEPT (and named biosimilars) — experimental, investigational, or unproven for: Polypoidal choroidal vasculopathy.; AFLIBERCEPT (and named biosimilars) — experimental, investigational, or unproven for: Prostate cancers.; AFLIBERCEPT (and named biosimilars) — experimental, investigational, or unproven for: Radiation retinopathy.; AFLIBERCEPT (and named biosimilars) — experimental, investigational, or unproven for: Retinitis pigmentosa.; AFLIBERCEPT (and named biosimilars) — experimental, investigational, or unproven for: Uterine leiomyosarcomas.; INTRAVITREAL BEVACIZUMAB (Avastin) and respective biosimilar injections — experimental, investigational, or unproven for the treatment of amelanotic melanoma / 'leakage' from an amelanotic choroid malignancy.; INTRAVITREAL BEVACIZUMAB (Avastin) and respective biosimilar injections — experimental, investigational, or unproven for the treatment of radiation maculopathy.; INTRAVITREAL BEVACIZUMAB (Avastin) and respective biosimilar injections — experimental, investigational, or unproven for hemorrhagic choroidal nevus.; SUBCONJUNCTIVAL INJECTION of bevacizumab (Avastin) and respective biosimilars — experimental, investigational, or unproven for the management of bleb encapsulation/needling following trabeculectomy.; INTRAVITREAL RANIBIZUMAB (Lucentis), ranibizumab (Susvimo), ranibizumab-eqrn (Cimerli), ranibizumab-nuna (Byooviz), bevacizumab (Avastin) and its respective biosimilar injections — experimental, investigational, or unproven (effectiveness not established; not an all-inclusive list) for: Amblyopia.; RANIBIZUMAB / BEVACIZUMAB (and biosimilars) — experimental, investigational, or unproven for: Central serous retinopathy.; RANIBIZUMAB / BEVACIZUMAB (and biosimilars) — experimental, investigational, or unproven for: Choroidal hemorrhage not related to a medically necessary indication.; RANIBIZUMAB / BEVACIZUMAB (and biosimilars) — experimental, investigational, or unproven for: Choroidal melanoma.; RANIBIZUMAB / BEVACIZUMAB (and biosimilars) — experimental, investigational, or unproven for: Coat's disease (Coates' disease, also known as exudative retinitis or retinal telangiectasis).; RANIBIZUMAB / BEVACIZUMAB (and biosimilars) — experimental, investigational, or unproven for: Cystoid macular edema.; RANIBIZUMAB / BEVACIZUMAB (and biosimilars) — experimental, investigational, or unproven for: Glaucoma surgery, control of wound healing.; RANIBIZUMAB / BEVACIZUMAB (and biosimilars) — experimental, investigational, or unproven for: Hypertensive retinopathy.; RANIBIZUMAB / BEVACIZUMAB (and biosimilars) — experimental, investigational, or unproven for: Primary pterygium (including as adjunctive therapy for primary pterygium surgery).; RANIBIZUMAB / BEVACIZUMAB (and biosimilars) — experimental, investigational, or unproven for: Radiation retinopathy.; RANIBIZUMAB / BEVACIZUMAB (and biosimilars) — experimental, investigational, or unproven for: Retinal angioma.; RANIBIZUMAB / BEVACIZUMAB (and biosimilars) — experimental, investigational, or unproven for: Sickle cell retinopathy.; RANIBIZUMAB / BEVACIZUMAB (and biosimilars) — experimental, investigational, or unproven for: Vitreous hemorrhage not related to a medically necessary indication.; TOPICAL administration, SUBCONJUNCTIVAL or INTRASTROMAL injections of ranibizumab, ranibizumab-eqrn, ranibizumab-nuna, bevacizumab and respective biosimilars — experimental, investigational, or unproven for the treatment of corneal neovascularization (effectiveness not established).; CONCURRENT USE of more than one VEGF inhibitor in the same eye — considered experimental, investigational, or unproven because the safety and effectiveness of combinational use of VEGF inhibitors for ocular indications has not been established. Claims may be denied when the requested service falls under these.

Does Aetna require prior authorization for Vascular Endothelial Growth Factor Inhibitors for Ocular Indications?

Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Prior authorization status is code-specific; this CPB is not an exact authorization source for every covered code. Check the Aetna precertification list or PA lookup for the exact code and plan context. Documentation: Statements of Medical Necessity must be submitted via the applicable Specialty Pharmacy Precertification forms for the precertification-required products.

What does Aetna exclude for Vascular Endothelial Growth Factor Inhibitors for Ocular Indications?

Policy exclusions and limitations: CONTRAINDICATION / NOT MEDICALLY NECESSARY (all VEGF inhibitors): VEGF inhibitors for ocular indications are contraindicated and considered not medically necessary for persons with endophthalmitis or with ocular or periocular infections.; ALL DRUGS: Aetna considers all other indications (not listed in the Criteria for Initial Approval for each respective drug) as not medically necessary; experimental, investigational, or unproven.; AFLIBERCEPT [(Eylea) and (Eylea HD)], aflibercept-abzv (Enzeevu), aflibercept-ayyh (Pavblu), aflibercept-boav (Eydenzelt), aflibercept-jbvf (Yesafili), aflibercept-mrbb (Ahzantive), or aflibercept-yszy (Opuviz) — experimental, investigational, or unproven (effectiveness not established; not an all-inclusive list) for: Central serous chorioretinopathy.; AFLIBERCEPT (and named biosimilars) — experimental, investigational, or unproven for: Choroidal neovascularization due to ocular histoplasmosis.; AFLIBERCEPT (and named biosimilars) — experimental, investigational, or unproven for: Colorectal cancer.; AFLIBERCEPT (and named biosimilars) — experimental, investigational, or unproven for: Cystoid macular edema.; AFLIBERCEPT (and named biosimilars) — experimental, investigational, or unproven for: Myopic choroidal neovascularization.; AFLIBERCEPT (and named biosimilars) — experimental, investigational, or unproven for: Neovascular glaucoma.; AFLIBERCEPT (and named biosimilars) — experimental, investigational, or unproven for: Ovarian cancer.; AFLIBERCEPT (and named biosimilars) — experimental, investigational, or unproven for: Polypoidal choroidal vasculopathy.; AFLIBERCEPT (and named biosimilars) — experimental, investigational, or unproven for: Prostate cancers.; AFLIBERCEPT (and named biosimilars) — experimental, investigational, or unproven for: Radiation retinopathy.; AFLIBERCEPT (and named biosimilars) — experimental, investigational, or unproven for: Retinitis pigmentosa.; AFLIBERCEPT (and named biosimilars) — experimental, investigational, or unproven for: Uterine leiomyosarcomas.; INTRAVITREAL BEVACIZUMAB (Avastin) and respective biosimilar injections — experimental, investigational, or unproven for the treatment of amelanotic melanoma / 'leakage' from an amelanotic choroid malignancy.; INTRAVITREAL BEVACIZUMAB (Avastin) and respective biosimilar injections — experimental, investigational, or unproven for the treatment of radiation maculopathy.; INTRAVITREAL BEVACIZUMAB (Avastin) and respective biosimilar injections — experimental, investigational, or unproven for hemorrhagic choroidal nevus.; SUBCONJUNCTIVAL INJECTION of bevacizumab (Avastin) and respective biosimilars — experimental, investigational, or unproven for the management of bleb encapsulation/needling following trabeculectomy.; INTRAVITREAL RANIBIZUMAB (Lucentis), ranibizumab (Susvimo), ranibizumab-eqrn (Cimerli), ranibizumab-nuna (Byooviz), bevacizumab (Avastin) and its respective biosimilar injections — experimental, investigational, or unproven (effectiveness not established; not an all-inclusive list) for: Amblyopia.; RANIBIZUMAB / BEVACIZUMAB (and biosimilars) — experimental, investigational, or unproven for: Central serous retinopathy.; RANIBIZUMAB / BEVACIZUMAB (and biosimilars) — experimental, investigational, or unproven for: Choroidal hemorrhage not related to a medically necessary indication.; RANIBIZUMAB / BEVACIZUMAB (and biosimilars) — experimental, investigational, or unproven for: Choroidal melanoma.; RANIBIZUMAB / BEVACIZUMAB (and biosimilars) — experimental, investigational, or unproven for: Coat's disease (Coates' disease, also known as exudative retinitis or retinal telangiectasis).; RANIBIZUMAB / BEVACIZUMAB (and biosimilars) — experimental, investigational, or unproven for: Cystoid macular edema.; RANIBIZUMAB / BEVACIZUMAB (and biosimilars) — experimental, investigational, or unproven for: Glaucoma surgery, control of wound healing.; RANIBIZUMAB / BEVACIZUMAB (and biosimilars) — experimental, investigational, or unproven for: Hypertensive retinopathy.; RANIBIZUMAB / BEVACIZUMAB (and biosimilars) — experimental, investigational, or unproven for: Primary pterygium (including as adjunctive therapy for primary pterygium surgery).; RANIBIZUMAB / BEVACIZUMAB (and biosimilars) — experimental, investigational, or unproven for: Radiation retinopathy.; RANIBIZUMAB / BEVACIZUMAB (and biosimilars) — experimental, investigational, or unproven for: Retinal angioma.; RANIBIZUMAB / BEVACIZUMAB (and biosimilars) — experimental, investigational, or unproven for: Sickle cell retinopathy.; RANIBIZUMAB / BEVACIZUMAB (and biosimilars) — experimental, investigational, or unproven for: Vitreous hemorrhage not related to a medically necessary indication.; TOPICAL administration, SUBCONJUNCTIVAL or INTRASTROMAL injections of ranibizumab, ranibizumab-eqrn, ranibizumab-nuna, bevacizumab and respective biosimilars — experimental, investigational, or unproven for the treatment of corneal neovascularization (effectiveness not established).; CONCURRENT USE of more than one VEGF inhibitor in the same eye — considered experimental, investigational, or unproven because the safety and effectiveness of combinational use of VEGF inhibitors for ocular indications has not been established. Claims may be denied when the requested service falls under these.

Source

Related

• All Aetna coverage policies
• Aetna prior-authorization requirements — which codes need PA, by CPT