CurrentClover HealthPolicy 7380-A

Jurisdiction Specific Medicare Part B Susvimo

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Prior authorization coverage for Susvimo (ranibizumab), including brand and generic products and all dosage forms and strengths, for Medicare Part B members in specified Medicare Administrative Contractor jurisdictions when applicable clinical criteria are met.

Policy Summary

PayerClover Health

PolicyJurisdiction Specific Medicare Part B Susvimo

Policy CodePolicy 7380-A

Change TypeNo material clinical or coverage changes

Effective DateN/A

Next Review DateN/A

Key ActionDocument the applicable diagnosis, prior response to at least two intravitreal injections of a VEGF inhibitor, and use in conjunction with the Susvimo ocular implant.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsMaximum authorization period

3Named covered ophthalmic indications

2 injectionsMinimum prior VEGF inhibitor response

10Included jurisdictions

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CurrentClover HealthPolicy 7380-A

Jurisdiction Specific Medicare Part B Susvimo

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Policy Summary

PayerClover Health

PolicyJurisdiction Specific Medicare Part B Susvimo

Policy CodePolicy 7380-A

Change TypeNo material clinical or coverage changes

Effective DateN/A

Next Review DateN/A

Key ActionDocument the applicable diagnosis, prior response to at least two intravitreal injections of a VEGF inhibitor, and use in conjunction with the Susvimo ocular implant.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsMaximum authorization period

3Named covered ophthalmic indications

2 injectionsMinimum prior VEGF inhibitor response

10Included jurisdictions

Neovascular wet AMD

Covered when ALL of the following are met:

Neovascular (wet) age-related macular degeneration

Diagnosis: Member has a diagnosis of neovascular (wet) age-related macular degeneration.
Prior VEGF inhibitor response: Member has previously responded to at least two intravitreal injections of a Vascular Endothelial Growth Factor (VEGF) inhibitor, such as Avastin or Eylea, within the past 6 months.At least 2 injections within the past 6 months
Ocular implant use: Must be used in conjunction with the Susvimo ocular implant.

Diabetic macular edema

Covered when ALL of the following are met:

Diagnosis: Member has a diagnosis of diabetic macular edema.
Prior VEGF inhibitor response: Member has previously responded to at least two intravitreal injections of a Vascular Endothelial Growth Factor (VEGF) inhibitor, such as Avastin or Eylea.At least 2 injections
Ocular implant use: Must be used in conjunction with the Susvimo ocular implant.

Diabetic retinopathy

Covered when ALL of the following are met:

Diagnosis: Member has a diagnosis of diabetic retinopathy.
Prior VEGF inhibitor response: Member has previously responded to at least two intravitreal injections of a Vascular Endothelial Growth Factor (VEGF) inhibitor, such as Avastin or Eylea.At least 2 injections
Ocular implant use: Must be used in conjunction with the Susvimo ocular implant.

All other approvable indications

Covered when the indication is approvable under the referenced Medicare coverage article:

Other approvable indications: Authorization of 12 months may be granted for treatment of all other approvable indications listed in LCA A52451.12 months authorization

Other indications are assessed individually.

Authorization and Documentation Requirements

Prior Authorization

Request 12-month authorization when criteria are met

Authorization may be granted for 12 months when the member meets the criteria for the applicable covered indication. All other approvable indications listed in LCA A52451 may also receive 12 months of authorization.

Step Therapy

Document prior VEGF inhibitor response

For neovascular wet age-related macular degeneration, diabetic macular edema, and diabetic retinopathy, document that the member previously responded to at least two intravitreal injections of a VEGF inhibitor, such as Avastin or Eylea.

For neovascular wet age-related macular degeneration, the injections must have occurred within the past 6 months.

Documentation Required

Support other indications with compendial evidence

For indications other than those specifically listed, submit supporting evidence from Medicare-approved compendia. Other indications will be assessed on an individual basis.

Documentation Required

Submit complete clinical documentation

For named indications, document the applicable diagnosis, prior response to at least two intravitreal injections of a VEGF inhibitor, and use in conjunction with the Susvimo ocular implant.

Applicable diagnoses include neovascular (wet) age-related macular degeneration, diabetic macular edema, and diabetic retinopathy.
VEGF inhibitor examples include Avastin and Eylea.

Denial Risk

Failure to meet criteria may result in denial

Coverage may be denied when the member does not have an applicable covered indication, does not meet all approval criteria, or has an exclusion to the prescribed therapy.

Note

Obtain individual review for other indications

Indications other than those listed in the policy are not automatically covered and will be assessed on an individual basis. Submit supporting evidence from Medicare-approved compendia for these requests.

Policy Background

Susvimo is the brand name for ranibizumab, including the brand and generic products and all dosage forms and strengths unless otherwise stated. This policy addresses coverage for ophthalmic treatment of neovascular (wet) age-related macular degeneration, diabetic macular edema, and diabetic retinopathy when the applicable approval criteria are met. For these indications, the member must have previously responded to at least 2 intravitreal injections of a VEGF inhibitor; treatment must also be used with the Susvimo ocular implant.

Policy Summary

PayerClover Health

PolicyJurisdiction Specific Medicare Part B Susvimo

Policy CodePolicy 7380-A

Change TypeNo material clinical or coverage changes

Effective DateN/A

Next Review DateN/A

Key ActionDocument the applicable diagnosis, prior response to at least two intravitreal injections of a VEGF inhibitor, and use in conjunction with the Susvimo ocular implant.

SourceLink

On This Page

Jurisdiction Specific Medicare Part B Susvimo

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Jurisdiction Specific Medicare Part B Susvimo

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Covered Indications and Eligibility

Authorization and Documentation Requirements

Policy Background

Key Terms