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    v1.0.31
    OpenPayerPolicy UpdatesOphthalmology/OptometryClover Health Beovu Prior Auth Coverage | OpenPaye…
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    CurrentClover HealthPolicy 3828-A

    Jurisdiction Specific Medicare Part B Beovu

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    This policy governs prior authorization and coverage of Beovu for Medicare Part B members in specified Medicare Administrative Contractor jurisdictions, including neovascular age-related macular degeneration and diabetic macular edema.

    Policy Summary
    PayerClover Health
    PolicyJurisdiction Specific Medicare Part B Beovu
    Policy CodePolicy 3828-A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionSubmit supporting evidence from Medicare-approved compendia for indications other than neovascular age-related macular degeneration or diabetic macular edema.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    12 monthsAuthorization duration
    2Covered indications
    10Jurisdiction states
    2Contractor jurisdictions

    Beovu Coverage Criteria

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Neovascular (Wet) Age-Related Macular Degeneration

    Covered when the indication is neovascular (wet) age-related macular degeneration, approval criteria are met, and the member has no exclusions to the prescribed therapy.

    Neovascular (wet) age-related macular degeneration: Treatment of neovascular (wet) age-related macular degeneration is eligible for authorization.Authorization period: 12 months

    Member must have no exclusions to the prescribed therapy.

    Diabetic Macular Edema

    Covered when the indication is diabetic macular edema, approval criteria are met, and the member has no exclusions to the prescribed therapy.

    Diabetic macular edema: Treatment of diabetic macular edema is eligible for authorization.Authorization period: 12 months

    Member must have no exclusions to the prescribed therapy.

    All Other Indications

    Other indications may be covered after individual assessment, provided the member has no exclusions to the prescribed therapy.

    Other approvable indications: Treatment of other approvable indications listed in LCA A52451 may be authorized after individual assessment.Authorization period: 12 months

    Submissions for indications other than those listed in this criteria should include supporting evidence from Medicare-approved compendia. Member must have no exclusions to the prescribed therapy.

    Authorization and Documentation Requirements

    Prior Authorization

    Wet Age-Related Macular Degeneration

    Authorization of 12 months may be granted for treatment of neovascular (wet) age-related macular degeneration when all applicable approval criteria are met and the member has no exclusions to the prescribed therapy.

    • Neovascular (wet) age-related macular degeneration
    • Authorization duration: 12 months
    • All approval criteria must be met.
    • The member must have no exclusions to the prescribed therapy.
    Prior Authorization

    Diabetic Macular Edema

    Authorization of 12 months may be granted for treatment of diabetic macular edema when all applicable approval criteria are met and the member has no exclusions to the prescribed therapy.

    • Diabetic macular edema
    • Authorization duration: 12 months
    • All approval criteria must be met.
    • The member must have no exclusions to the prescribed therapy.
    Prior Authorization

    Other Approvable Indications

    Authorization of 12 months may be granted for treatment of other approvable indications listed in LCA A52451. All other indications are assessed on an individual basis.

    • The indication must be an approvable indication listed in LCA A52451.
    • Authorization duration: 12 months.
    • Indications outside the listed criteria are assessed individually.
    Documentation Required

    Compendial Support and Documentation

    For indications other than those listed in the policy criteria, submit supporting evidence from Medicare-approved compendia. Covered compendial uses must have ICD-10 codes supported by the Medicare Administrative Contractor.

    • The complete list of covered ICD-10 codes is available through the CMS Medicare Coverage Database national and local indexes: https://www.cms.gov/medicare-coverage-database/indexes/national-and-local-indexes.aspx.
    • Include supporting evidence from Medicare-approved compendia for other indications.
    • The Medicare Administrative Contractor must support the applicable ICD-10 code.
    Denial Risk

    Denial Risk: Unmet or Unsupported Criteria

    Coverage is not assured when applicable approval criteria are not met, the member has an exclusion to the prescribed therapy, or the indication is not supported under the policy. Indications other than those listed in the criteria require individual assessment and supporting evidence from Medicare-approved compendia.

    • Failure to meet all approval criteria may result in denial.
    • Exclusions to the prescribed therapy may prevent coverage.
    • Unsupported indications are not automatically covered.
    • Other indications must be assessed individually and supported by Medicare-approved compendia.

    Policy Background

    Beovu (brolucizumab-dbll) is an ophthalmic biologic used to treat retinal vascular diseases. Under this Medicare Part B policy, coverage is available for neovascular (wet) age-related macular degeneration and diabetic macular edema when approval criteria are met and the member has no exclusions to the prescribed therapy. Other approvable indications may be considered individually when supported by Medicare-approved compendia and applicable Medicare Administrative Contractor coverage guidance.

    Policy Summary
    PayerClover Health
    PolicyJurisdiction Specific Medicare Part B Beovu
    Policy CodePolicy 3828-A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionSubmit supporting evidence from Medicare-approved compendia for indications other than neovascular age-related macular degeneration or diabetic macular edema.
    SourceLink
    On This Page
    Beovu Coverage CriteriaAuthorization and Documentation RequirementsPolicy Background