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ModifiedAmerihealth Caritas VIP CarePolicy MA08.073w

Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists, VEGF Biosimilars, and Combination VEGF/Angiopoietin (Ang-2) Inhibitors

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Part B medical-benefit coverage and medical necessity for intravitreal aflibercept, aflibercept HD, bevacizumab, brolucizumab, faricimab, ranibizumab, and related biosimilars for vascular diseases of the eye in Medicare Advantage members.

Policy Summary

PayerAmerihealth Caritas VIP Care

PolicyIntravitreal VEGF Antagonists, Biosimilars, and VEGF/Ang-2 Inhibitors

Policy CodePolicy MA08.073w

Change TypeModified

Effective DateSeptember 18, 2026

Next Review DateN/A

Key ActionDocument that inadequate response follows at least three monthly injections at FDA-labeled doses.

SourceLink

POLICY UPDATE CHANGES

The policy added a criterion that inadequate response is determined after at least three monthly injections administered at doses consistent with FDA labeling.

Ranibizumab-leyk (Nufymco) was added as medically necessary in accordance with FDA labeling.

HCPCS codes Q5168 for ranibizumab-leyk and Q5170 for aflibercept-boav were added to the policy.

Aflibercept HD was expanded to include macular edema following retinal vein occlusion, and Susvimo indications were revised to include diabetic macular edema and diabetic retinopathy.

HCPCS code Q5160 for bevacizumab-nwgd (Jobevne) was added.

Pegaptanib sodium (Macugen) was designated not eligible for reimbursement.

18HCPCS codes listed as medically necessary

3Minimum treatment course for inadequate response

7Named drug products or formulations addressed

J2503Pegaptanib code withdrawn and not eligible for reimbursement

Drug-Specific Coverage Criteria

Aflibercept (Eylea) and Related Biosimilars

The intravitreal injection of VEGF antagonist aflibercept (Eylea) and related biosimilars is considered medically necessary and, therefore, covered for vascular diseases of the eye including, but not limited to, the following:

ALL of the following

Neovascular (wet or exudative) age-related macular degeneration (AMD)
Macular edema following retinal vein occlusion (RVO)
Diabetic macular edema (DME)
Diabetic retinopathy (DR)
Retinopathy of prematurity (ROP)

Policy Summary

PayerAmerihealth Caritas VIP Care

PolicyIntravitreal VEGF Antagonists, Biosimilars, and VEGF/Ang-2 Inhibitors

Policy CodePolicy MA08.073w

Change TypeModified

Effective DateSeptember 18, 2026

Next Review DateN/A

Key ActionDocument that inadequate response follows at least three monthly injections at FDA-labeled doses.

SourceLink

On This Page

Bevacizumab (Avastin) and Related Biosimilars

The intravitreal injection of VEGF antagonist bevacizumab (Avastin) and related biosimilars is considered medically necessary and, therefore, covered for vascular diseases of the eye including, but not limited to, the following:

ALL of the following

Choroidal neovascularization due to angioid streaks, central serous chorioretinopathy, choroidal rupture or trauma, idiopathic choroidal neovascularization, multifocal choroiditis, pathologic myopia, presumed ocular histoplasmosis syndrome, or uveitis
Diabetic macular edema (DME)
Diabetic retinopathy (DR)
Macular edema following retinal vein occlusion (RVO)
Neovascular (wet or exudative) age-related macular degeneration (AMD)
Neovascular glaucoma
Retinopathy of prematurity (ROP)

Brolucizumab, Faricimab, and Ranibizumab

The intravitreal injections of brolucizumab-dbll (Beovu), faricimab-svoa (Vabysmo), ranibizumab (Lucentis), ranibizumab-leyk (Nufymco), and related biosimilars are considered medically necessary and, therefore, covered for the listed vascular diseases of the eye, including but not limited to the following:

Brolucizumab-dbll (Beovu) and related biosimilars

Neovascular (wet or exudative) age-related macular degeneration (AMD)
Diabetic macular edema (DME)

Faricimab-svoa (Vabysmo) and related biosimilars

Neovascular (wet or exudative) age-related macular degeneration (AMD)
Diabetic macular edema (DME)
Macular edema following retinal vein occlusion (RVO)

Ranibizumab (Lucentis), ranibizumab-leyk (Nufymco), and related biosimilars

Neovascular (wet or exudative) age-related macular degeneration (AMD)
Macular edema following retinal vein occlusion (RVO)
Diabetic macular edema (DME)
Diabetic retinopathy (DR)
Retinopathy of prematurity (ROP)
Choroidal neovascularization due to angioid streaks, central serous chorioretinopathy, choroidal rupture or trauma, idiopathic choroidal neovascularization, multifocal choroiditis, pathologic myopia, presumed ocular histoplasmosis syndrome, or uveitis

The use of more than one VEGF antagonist product and/or combination VEGF/angiopoietin-2 (Ang-2) inhibitor product in the same eye, in a concurrent and/or alternating manner, is considered experimental/investigational and, therefore, not covered because the use is not supported by professional medical practice guidelines or a review of the currently published peer-reviewed literature.

All other uses of aflibercept (Eylea), aflibercept HD (Eylea HD), bevacizumab (Avastin), brolucizumab-dbll (Beovu), faricimab-svoa (Vabysmo), ranibizumab (Lucentis, Susvimo), and related biosimilars are considered experimental/investigational and, therefore, not covered unless the indication is supported as an accepted off-label use, as defined in the medical policy on off-label coverage for prescription drugs and biologics.

Initial Therapy

Initial therapy is medically necessary and covered when the requested product is used for a listed vascular disease of the eye and the applicable drug-specific indication criteria are met.

Drug-specific covered indication

Aflibercept (Eylea) or related biosimilar: The individual has neovascular age-related macular degeneration, macular edema following retinal vein occlusion, diabetic macular edema, diabetic retinopathy, or retinopathy of prematurity.
Aflibercept HD (Eylea HD) or related biosimilar: The individual has neovascular age-related macular degeneration, diabetic macular edema, diabetic retinopathy, or macular edema following retinal vein occlusion.
Bevacizumab (Avastin) or related biosimilar: The individual has a listed qualifying condition: specified choroidal neovascularization, diabetic macular edema, diabetic retinopathy, macular edema following retinal vein occlusion, neovascular age-related macular degeneration, neovascular glaucoma, or retinopathy of prematurity.
Brolucizumab (Beovu) or related biosimilar: The individual has neovascular age-related macular degeneration or diabetic macular edema.
Faricimab (Vabysmo) or related biosimilar: The individual has neovascular age-related macular degeneration, diabetic macular edema, or macular edema following retinal vein occlusion.
Ranibizumab (Lucentis) or related biosimilar: The individual has neovascular age-related macular degeneration, macular edema following retinal vein occlusion, diabetic macular edema, diabetic retinopathy, retinopathy of prematurity, or a listed form of choroidal neovascularization.
Ranibizumab (Susvimo) ocular implant
- ONE qualifying diagnosis
  - Neovascular age-related macular degeneration.
  - Diabetic macular edema.
  - Diabetic retinopathy.
- The individual requires VEGF antagonist treatment every month.Monthly VEGF antagonist treatment required

Continuation Therapy

Covered for continuation therapy when ALL of the following are met.

Continuation criteria

Initial-therapy medical necessity criteria were met.
Medical records show documented improvement or stabilization in visual acuity.
The professional provider orders continued treatment with the requested drug.

Continuation Therapy — Added Policy Criterion

Continuation therapy criteria apply to VEGF antagonists and VEGF/Ang-2 inhibitors when ALL of the following are met.

Continuation therapy requirements

The individual has met the medical necessity criteria for initial therapy.
Medical records document improvement or stabilization in visual acuity.
The professional provider orders continued treatment with the requested drug.

Billing and Diagnosis Codes

CPT Procedure Code Number(s)CPT

No codes listed

ICD-10 Procedure Code Number(s)ICD-10

No codes listed

ICD-10 Diagnosis Code Number(s)ICD-10

No codes listed

Medically Necessary HCPCS Level II CodesHCPCSCovered

C9257	Injection, bevacizumab, 0.25 mg
J0177	Injection, aflibercept hd, 1 mg
J0178	Injection, aflibercept, 1 mg
J0179	Injection, brolucizumab-dbll, 1 mg
J2777	Injection, faricimab-svoa, 0.1 mg
J2778	Injection, ranibizumab, 0.1 mg
J2779	Injection, ranibizumab, via intravitreal implant (susvimo), 0.1 mg
J9035	Injection, bevacizumab, 10 mg
Q5107	Injection, bevacizumab-awwb, biosimilar (mvasi), 10 mg
Q5118	Injection, bevacizumab-bvzr, biosimilar (zirabev), 10 mg

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Codes Used to Represent Bevacizumab-tnjn (Avzivi)HCPCSCovered

C9399	Unclassified drugs or biologics
J3590	Unclassified biologics

Revenue Code Number(s)Revenue

No codes listed

Historical and added HCPCS codes for unclassified drugs and high-dose afliberceptHCPCS

C9399	Unclassified drugs or biologicals
J3590	Unclassified biologics
J0177	Injection, aflibercept hd, 1 mg
C9161	Injection, aflibercept hd, 1 mg

VEGF antagonist, biosimilar, and combination inhibitor HCPCS codesHCPCS

J2777	Injection, faricimab-svoa, 0.1 mg
J2779	Injection, ranibizumab, via intravitreal implant (Susvimo), 0.1 mg
J2503	Injection, pegaptanib sodium, 0.3 mg
Q5128	Injection, ranibizumab-eqrn, biosimilar, 0.1 mg
Q5129	Injection, bevacizumab-adcd, biosimilar, 10 mg
Q5126	Injection, bevacizumab-maly, biosimilar, (Alymsys), 10 mg
C9399	Unclassified drugs or biologicals
J3590	Unclassified biologics

Beovu and Zirabev HCPCS codesHCPCSCovered

J0179	Injection, brolucizumab-dbll, 1 mg
Q5118	Injection, bevacizumab-bvcr, biosimilar, (Zirabev), 10 mg

Historical diagnosis codes referenced for Beovu, Eylea, Avastin, and LucentisICD-10

H35.82	Retinal ischemia
H35.89	Other specified retinal disorders
H34.8110-H34.8190	Central retinal vein occlusion, with macular edema
H34.8111-H34.8191	Central retinal vein occlusion, with retinal neovascularization
H34.8310-H34.8390	Tributary (branch) retinal vein occlusion, with macular edema
H34.8311-H34.8391	Tributary (branch) retinal vein occlusion, with retinal neovascularization
H20.011-H20.019	Primary iridocyclitis
H20.021-H20.029	Recurrent acute iridocyclitis
H20.031-H20.039	Secondary infectious iridocyclitis
H20.041-H20.049	Secondary noninfectious iridocyclitis

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Historical Lucentis diagnosis codesICD-10

H44.2A1	Degenerative myopia with choroidal neovascularization, right eye
H44.2A2	Degenerative myopia with choroidal neovascularization, left eye
H44.2A3	Degenerative myopia with choroidal neovascularization, bilateral eye
H44.2A9	Degenerative myopia with choroidal neovascularization, unspecified eye
H44.2B1	Degenerative myopia with macular hole, right eye
H44.2B2	Degenerative myopia with macular hole, left eye
H44.2B3	Degenerative myopia with macular hole, bilateral eye
H44.2B9	Degenerative myopia with macular hole, unspecified eye
H44.2C1	Degenerative myopia with retinal detachment, right eye
E08.3521	ICD-10-CM code added for Lucentis

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Diagnosis codes removed from Attachment AICD-10Not Covered

H34.00	Code removed from Attachment A
H34.01	Code removed from Attachment A
H34.02	Code removed from Attachment A
H34.03	Code removed from Attachment A
H34.10	Code removed from Attachment A
H34.11	Code removed from Attachment A
H34.12	Code removed from Attachment A
H34.13	Code removed from Attachment A
H34.211	Code removed from Attachment A
H34.212	Code removed from Attachment A

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ICD-10 codes added or listed as added in the 2016 coding updateICD-10Covered

H34.8110	Central retinal vein occlusion, right eye, with macular edema
H34.8111	Central retinal vein occlusion, right eye, with retinal neovascularization
H34.8112	Central retinal vein occlusion, right eye, stable proliferative retinopathy
H34.8120	Central retinal vein occlusion, left eye, with macular edema
H34.8121	Central retinal vein occlusion, left eye, with retinal neovascularization
H34.8122	Central retinal vein occlusion, left eye, stable proliferative retinopathy
H34.8130	Central retinal vein occlusion, bilateral, with macular edema
H34.8131	Central retinal vein occlusion, bilateral, with retinal neovascularization
H34.8132	Central retinal vein occlusion, bilateral, stable proliferative retinopathy
H34.8190	Central retinal vein occlusion, unspecified eye, with macular edema

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ICD-10 codes removed for Eylea, Macugen, and LucentisICD-10Not Covered

E08.3521-E08.3559	Listed E08 diabetic ophthalmic complication codes removed from the policy
E09.3521-E09.3559	Listed E09 diabetic ophthalmic complication codes removed from the policy
E10.3521-E10.3559	Listed E10 diabetic ophthalmic complication codes removed from the policy
E11.3521-E11.3559	Listed E11 diabetic ophthalmic complication codes removed from the policy
E13.3521-E13.3559	Listed E13 diabetic ophthalmic complication codes removed from the policy
H34.11	Central retinal artery occlusion, right eye
H34.12	Central retinal artery occlusion, left eye
H34.13	Central retinal artery occlusion, bilateral
H34.231	Branch retinal artery occlusion, right eye
H34.232	Branch retinal artery occlusion, left eye

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ICD-10 codes removed for Lucentis onlyICD-10Not Covered

H21.1X1	Hyphema, right eye
H21.1X2	Hyphema, left eye
H21.1X3	Hyphema, bilateral
H44.2C2	Degenerative myopia with retinal detachment, left eye
H44.2C3	Degenerative myopia with retinal detachment, bilateral eye
H44.2C9	Degenerative myopia with retinal detachment, unspecified eye
H44.2D1	Degenerative myopia with foveoschisis, right eye
H44.2D2	Degenerative myopia with foveoschisis, left eye
H44.2D3	Degenerative myopia with foveoschisis, bilateral eye
H44.2D9	Degenerative myopia with foveoschisis, unspecified eye

1–10 of 14

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Legacy ICD-10 codes deleted in the 2026 policy versionICD-10Not Covered

H34.811	Deleted legacy code
H34.812	Deleted legacy code
H34.813	Deleted legacy code
H34.831	Deleted legacy code
H34.832	Deleted legacy code
H34.833	Deleted legacy code
H35.31	Deleted legacy code
H35.32	Deleted legacy code
E08.321	Deleted legacy code
E08.331	Deleted legacy code

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Inadequate Response

Inadequate responseDetermined after administering at least three (3) monthly injections.

Dose requirementInjections must be administered at doses in accordance with FDA labeling.

Effective dateSeptember 18, 2026.

Documentation and Coverage Responsibilities

Documentation Required

Medical-Record Documentation Required

Ensure the individual's medical record reflects the medical necessity for the care provided. Maintain records from applicable care settings and make all supporting documentation available to the Company upon request; failure to produce requested information may result in denial for the drug.

Documentation may include records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.
The Company may review and audit services regardless of provider participation status.

Documentation Required

Document Continuation Therapy

For continuation therapy, document that the individual met the initial-therapy medical-necessity criteria and that treatment remains clinically appropriate. The medical record must show visual improvement or stabilization and the professional provider's order to continue treatment with the requested drug.

Documented improvement or stabilization in visual acuity.
Professional provider orders continued treatment with the requested drug.

Billing Rule

Use Accurate Coding and Diagnosis Support

Report the billing codes and modifiers that most accurately represent the services rendered and submit the most appropriate diagnosis code supporting the policy's medically necessary criteria. Coding-table inclusion does not guarantee reimbursement; eligibility, benefits, limitations, exclusions, precertification or referral requirements, provider contracts, and Company policies still apply.

Apply nationally accepted coding guidelines, including future applicable coding changes, revisions, or updates.
Report the most appropriate ICD-10 diagnosis code in support of the medically necessary criteria.

Documentation Required

Document Inadequate Response

When documenting an inadequate response, show that the individual received at least three monthly injections at doses consistent with FDA labeling.

At least three (3) monthly injections are required to determine an inadequate response.
Doses must be in accordance with FDA labeling.

Denial Risk

Avoid Uncovered Indications and Multiple Products in One Eye

Do not bill or seek coverage for uses identified as experimental/investigational unless the indication is supported as an accepted off-label use under the applicable medical policy. Using more than one VEGF antagonist and/or combination VEGF/Ang-2 inhibitor in the same eye concurrently or in an alternating manner is not covered.

Other uses of aflibercept, aflibercept HD, bevacizumab, brolucizumab-dbll, faricimab-svoa, ranibizumab, and related biosimilars are experimental/investigational unless supported as an accepted off-label use.
More than one VEGF antagonist product and/or combination VEGF/Ang-2 inhibitor product in the same eye is considered experimental/investigational and not covered.

Unsupported block type: billing_rule деноial_risk???

Denial Risk

Macugen Is Not Eligible for Reimbursement

Do not submit pegaptanib sodium (Macugen) for reimbursement. Macugen has been withdrawn from the market and is no longer eligible for reimbursement.

HCPCS J2503 (injection, pegaptanib sodium, 0.3 mg) is not eligible for reimbursement.

Clinical Terms and Products

Vascular Diseases of the Eye

DefinitionVascular diseases of the eye are ocular conditions involving abnormal blood-vessel growth, leakage, vascular permeability, or impaired retinal blood flow.

Representative conditionsNeovascular (wet or exudative) age-related macular degeneration, diabetic macular edema, diabetic retinopathy, and retinal vein occlusion-associated macular edema.

Additional covered conditionsSelected forms of choroidal neovascularization and retinopathy of prematurity are also included among representative vascular diseases of the eye.

Accepted Off-Label Use

DefinitionAn accepted off-label use is an indication supported under the Company's separate medical policy addressing off-label coverage for prescription drugs and biologics.

Coverage relationshipUses outside the listed medically necessary indications are not covered unless supported as an accepted off-label use.

Applicable policyThe separate medical policy on off-label coverage for prescription drugs and biologics determines whether the use is supported.

Neovascular (Wet or Exudative) Age-Related Macular Degeneration

DefinitionA retinal condition caused by abnormal blood vessels beneath the macula.

Disease processThe abnormal vessels leak blood and fluid.

Potential consequenceThe leakage can lead to vision loss.

Diabetic Macular Edema

DefinitionMacular edema associated with diabetes.

Visual effectsIt can cause blurred vision and severe vision loss.

Severe outcomeIn some cases, it can cause blindness.

Retinal Vein Occlusion

DefinitionMacular edema and retinal hemorrhage resulting from blockage of normal blood flow through a retinal vein.

Anatomic classificationsThe obstruction may involve the central retinal vein or one of its branches.

Potential consequenceThe resulting edema and hemorrhaging in the retina can lead to vision loss.

Choroidal Neovascularization

DefinitionAbnormal blood vessels begin growing in the choroid, the area beneath the retina.

Anatomic extensionThe vessels grow into the subretinal space.

Disease processThe abnormal vessels leak blood and fluid, which can lead to vision loss.

Faricimab

Drug classHumanized bispecific IgG1 antibody.

Primary targetBinds vascular endothelial growth factor A (VEGF-A).

Additional targetBinds angiopoietin-2 (Ang-2).

Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists, VEGF Biosimilars, and Combination VEGF/Angiopoietin (Ang-2) Inhibitors

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Drug-Specific Coverage Criteria

Initial Therapy

Continuation Therapy

Billing and Diagnosis Codes

Documentation and Coverage Responsibilities

Policy Background

Clinical Terms and Products