Prior Authorization Required

Prior authorization (precertification) is required for select intravitreal agents and associated injection procedure codes. Requests should indicate the ocular indication, planned dosing regimen (including loading and maintenance schedules), prior therapies or contraindications when applicable, and objective disease‑activity measures. Documentation must support clinical justification, dosing frequency, prior response (when required), and absence of contraindications; lack of required precertification may result in claim denial.

• Precertification required for: aflibercept (Eylea, Eylea HD), brolucizumab-dbll (Beovu), faricimab-svoa (Vabysmo), pegaptanib (Macugen), ranibizumab products (Lucentis, Susvimo, Cimerli, Byooviz). Call (866) 752-7021 or fax (888) 267-3277 for precertification; SMN forms available via Aetna Specialty Pharmacy Precertification.
• Prior authorization applies to intravitreal injection CPT 67028 and relevant HCPCS codes (examples: J2503, J0179, C9257, J2778, J2779, J9035 and biosimilar Q‑codes). Submit the specific HCPCS/CPT code that corresponds to the billed agent.
• Authorization requests should state the indication (e.g., nAMD, DME, RVO, DR, ROP), the exact dosing regimen planned (loading doses and intended maintenance interval or PRN/PTI schedule), and the clinical rationale for agent selection including prior therapies and reason for switch or off‑label use.
• For Susvimo (ranibizumab implant) and Beovu (brolucizumab), authorization is expected to be indication‑ and dosing‑specific: Susvimo requires prior documented response to ≥2 prior intravitreal VEGF injections per FDA indication; Beovu dosing must reflect approved loading and individualized q8/q12 (or study‑based) maintenance intervals.
• Prior authorization may be required or scrutinized for off‑label use (e.g., bevacizumab/Avastin or biosimilars for ophthalmic indications) or for switching between agents after inadequate response; document prior failure, intolerance, or contraindication to FDA‑approved alternatives when applicable.
• Clinical justification should include baseline and follow‑up objective measures (BCVA/ETDRS letters or Snellen equivalents, OCT central subfield/central foveal thickness), prior treatment history (dates, agents, response), and planned monitoring and retreatment criteria.
• Contraindications that may trigger denial include active ocular or periocular infection, active intraocular inflammation, or documented hypersensitivity to the agent; presence of such conditions should be clearly reported and will preclude authorization.
• Be aware of denied claims risk when billed with ICD‑10 codes not covered per the policy’s CPB list; verify that the submitted diagnosis code is among those covered when selection criteria are met.
• Evidence limitations and methodological concerns (especially for off‑label bevacizumab ophthalmic use) may affect authorization decisions; AAO guidance supports reimbursement for bevacizumab only for patients who have failed FDA‑approved therapies or when treating physician documents expected benefit.
• If the policy excerpt does not specify an administrative prior‑authorization rule for a given agent or code, follow Aetna’s general precertification channels and note that absence of explicit authorization language in the excerpt does not imply no prior authorization may be required.
• Procedural documentation note: implant insertion, refill‑exchange, and implant removal (Susvimo) require strict aseptic procedural documentation and may have additional coding/operational requirements.
• When requesting authorization for dosing regimens based on clinical trials, align the requested schedule (loading doses then q8–q12, q16 etc., or PTI rules) with the trial‑supported regimen and document disease‑activity criteria that will guide interval adjustments.
• When switching after inadequate response, include prior injection dates, number of injections, objective measures at time of switch (CFT, BCVA), and rationale for selecting the new agent (e.g., durability, fewer injections, anatomical nonresponse).
• For products with product‑ and indication‑specific authorization requirements (e.g., Susvimo, biosimilars/interchangeables), indicate the exact product name (reference or biosimilar/interchangeable) and the FDA‑required prior exposure or response documentation.
• Some indications remain experimental or investigational (e.g., certain uses of aflibercept, bevacizumab for radiation maculopathy or other non‑established conditions); such uses may be excluded from authorization.

Required Clinical Documentation

Providers must include the following clinical documentation with prior authorization requests to support medical necessity and dosing decisions.

• Diagnosis with laterality and stage/severity when applicable (e.g., CRVO vs BRVO, ischemic vs non‑ischemic, ROP zone/stage).
• Baseline and recent BCVA (ETDRS letters or Snellen) and change from baseline.
• OCT measures: central subfield thickness / central foveal thickness and other relevant imaging (fluorescein angiography, ICGA) where used to document activity.
• Prior treatment history: agents, dates, number of injections, response (anatomic and visual), prior surgeries or laser photocoagulation, and documented contraindications or intolerances to alternatives.
• Planned dosing regimen: loading doses, maintenance interval (fixed, PRN, PTI), retreatment criteria, and expected monitoring schedule.
• For Susvimo: documentation of prior response to at least two intravitreal VEGF injections within the relevant timeframe per FDA indication; for switches, evidence of inadequate response to prior agent(s).
• Clinical trial‑based rationale when requesting trial‑style or extended interval regimens (cite trial regimen used to justify planned dosing).

Billing Code Specificity and ICD‑10 Risk

Billing and coding guidance — submit the specific CPT/HCPCS code corresponding to the agent and procedure. CPT 67028 is the intravitreal injection procedure code; submit the drug HCPCS/J‑code or Q‑code for the specific VEGF agent billed. Use appropriate diagnosis (ICD‑10) codes covered by the CPB to avoid denial.

• Procedure code: CPT 67028 (Intravitreal injection of a pharmacologic agent).
• Agent HCPCS/HCPCS J/Q examples: J0178 (aflibercept, 1 mg), C9161 (aflibercept HD, 1 mg), J0179 (brolucizumab, 1 mg), J2778 (ranibizumab, 0.1 mg), J2779 (ranibizumab via implant, 0.1 mg), J9035/C9257/Q5107/Q5118/Q5124 etc. for bevacizumab/rabiosimilars and ranibizumab biosimilars — bill the exact code matching the product and dose.
• ICD‑10: verify that the diagnosis code is among those covered for the selected agent per policy; codes listed as not covered for CPB indications may result in denial if used.

Denial Risk and Policy Limits

Clinical and administrative denial risks and policy limitations to watch for when requesting authorization.

• Missing precertification/SMN when required may trigger denial.
• Contraindications (ocular/periocular infection, active intraocular inflammation, hypersensitivity) present at time of request will preclude authorization.
• Some uses are considered experimental/investigational (e.g., certain indications listed for aflibercept, bevacizumab for radiation maculopathy, others in the CPB) and are not eligible for authorization.
• Evidence limitations (small sample sizes, retrospective designs, lack of control) — particularly for off‑label bevacizumab safety data — may influence authorization for non‑standard uses.
• For ischemic CRVO‑ME and other indications lacking evidence of benefit, requests may be denied as investigational.

Step‑Therapy and Agent Selection

Step‑therapy and product selection considerations: Aetna’s approach emphasizes use of less costly alternatives when therapeutically equivalent and supports use of biosimilars per policy; concurrent use of more than one VEGF inhibitor in the same eye is considered experimental.

• Brand selection/step: Byooviz, Cimerli, Alymsys, Eylea, Lucentis, Mvasi, Susvimo, Vabysmo, Vegzelma, Zirabev are considered medically necessary only when member has contraindication, intolerance, or ineffective response to lower-cost alternatives (e.g., Avastin) for listed indications.
• Monotherapy requirement: concurrent use of >1 VEGF inhibitor in the same eye is experimental/investigational and is not supported.
• Step therapy: No single mandated step sequence is specified in the excerpt, but switching after inadequate response is supported when documented; provide prior treatment history and objective measures to justify switch.
• Agent selection may consider cost and FDA‑approved indication; comparative trial data (e.g., trials comparing brolucizumab, faricimab, aflibercept) may inform choice and durability expectations.

Procedural and Product‑Specific Notes

Operational notes and special product requirements to include with prior authorization or claims.

• Susvimo: prior authorization must document prior response to intravitreal VEGF therapy (≥2 injections), planned implant/refill schedule, and awareness of implant‑specific risks; implant procedures (insertion, refill‑exchange, removal) require aseptic procedural documentation.
• Beovu and Vabysmo: authorization should reflect FDA‑approved indication and dosing schedules (loading doses and maintenance intervals informed by trials); note Beovu and Vabysmo contraindications (ocular/periocular infection, active intraocular inflammation, hypersensitivity) in requests.
• Procedural documentation: include operative notes when implant procedures are performed and document adherence to aseptic technique and implant‑specific monitoring.