Intravitreal bevacizumab (Avastin)
Intravitreal bevacizumab (Avastin) injections is considered medically necessary for the treatment of the following indications:
Diabetic macular edema
Proliferative diabetic retinopathy
Macular edema following retinal vein occlusion (BRVO)
Neovascular (wet) AMD
Neovascular glaucoma
Polypoidal choroidal vasculopathy
Choroidal neovascularization, (including myopic choroidal neovascularization (mCNV), angioid streaks, choroiditis [including choroiditis secondary to ocular histoplasmosis], idiopathic degenerative myopia, retinal dystrophies, rubeosis iridis, pseudoxanthoma elasticum, and trauma)
Retinopathy of prematurity
Intravitreal bevacizumab (Avastin) injections is considered investigational for any other ophthalmological indications not mentioned above.
Ranibizumab (Lucentis)/Ranibizumab-eqrn (Cimerli)
Intravitreal ranibizumab (Lucentis) or Ranibizumab-eqrn (Cimerli) is considered medically necessary for the treatment of the following indications:
Diabetic macular edema
Diabetic retinopathy
Macular edema following retinal vein occlusion (BRVO)
Myopic choroidal neovascularization
Neovascular (wet) AMD
Ranibizumab-eqrn (Cimerli) is interchangeable with ranibizumab (Lucentis).
Intravitreal ranibizumab (Lucentis) or Ranibizumab-eqrn (Cimerli) is considered investigational for any other ophthalmological indications not mentioned above.
Ranibizumab (Susvimo)
Intravitreal ranibizumab (Susvismo) is considered medically necessary for the treatment of the following indications:
Neovascular (wet) AMD who have previously responded to at least two intravitreal injections of a VEGF inhibitor.
Intravitreal ranibizumab (Susvismo) is considered investigational for any other ophthalmological indications not mentioned above.
Intravitreal aflibercept (Eylea)
Intravitreal aflibercept (Eylea) is considered medically necessary for the treatment of the following indications:
Diabetic macular edema
Diabetic retinopathy
Macular edema following retinal vein occlusion (including central retinal vein occlusion (CRVO) and branch retinal vein occlusion (BRVO)
Neovascular (wet) AMD.
Retinopathy of prematurity (ROP) with zone I (stage 1+, 2+, 3 or 3+), zone II (stage 2+ or 3+)
or AP-ROP (aggressive posterior ROP) disease.
Intravitreal aflibercept (Eylea) is considered investigational for any other ophthalmological indications not mentioned above.
Intravitreal brolucizumab-dbll (Beovu)
Brolucizumab-dbll intravitreal injection (Beovu) is considered medically necessary for the treatment of neovascular (wet) age-related macular degeneration.
Brolucizumab-dbll intravitreal injection (Beovu) is considered investigational for any other ophthalmological indications not mentioned above.
Pegaptanib sodium injection (Macugen)
Pegaptanib sodium injection (Macugen) is considered medically necessary for the treatment of individuals with neovascular (wet) age-related macular degeneration (AMD).
Pegaptanib sodium injection (Macugen) is considered investigational for any other ophthalmological indications not mentioned above.
Ranibizumab-nuna (Byooviz)
Intravitreal ranibizumab-nuna (Byooviz) is considered medically necessary for the treatment of the following indications:
Macular edema following retinal vein occlusion (RVO)
Neovascular (Wet) Age-Related Macular Degeneration (AMD).
Myopic Choroidal Neovascularization (mCNV)
Intravitreal ranibizumab-nuna (Byooviz) is considered investigational for any other ophthalmological indications not mentioned above.
Faricimab-svoa (Vabysmo)
Intravitreal Faricimab-svoa (Vabysmo) is considered medically necessary for the treatment of the following indications:
Diabetic macular edema (DME)
Neovascular (Wet) Age-Related Macular Degeneration (AMD).
Intravitreal Faricimab-svoa (Vabysmo) is considered investigational for any other ophthalmological indications not mentioned above.
