Intravitreal injections and implants are considered medically necessary when the following agent‑specific indications, dosing, and prerequisites are met.
Anti‑VEGF agents (ranibizumab, aflibercept, brolucizumab, faricimab, bevacizumab and biosimilars, others): Covered indications include neovascular (wet) age‑related macular degeneration (AMD), diabetic macular edema (DME), diabetic retinopathy (DR) with DME, macular edema following retinal vein occlusion (RVO), myopic choroidal neovascularization (mCNV), retinal neovascularization and other listed retinal conditions when consistent with the agent's labeled uses and this policy.
See individual agent entries for dosing and prior‑therapy requirements; some agents are covered under separate LCDs for Medicare members (e.g., Beovu, Eylea, Eylea HD, Byooviz, Cimerli, Lucentis, Pavblu, Vabysmo) per the policy.
Agent‑specific dosing (examples): Follow the dosing regimens listed for each product: e.g., Lucentis 0.5 mg intravitreally every ~28 days; Cimerli/Byooviz 0.5 mg monthly (or 0.3 mg variants per indication); Eylea 2 mg every 4 weeks for initial doses then 2 mg every 8 weeks (with specified initial/maintenance separation for some indications); Beovu 6 mg q4 weeks x3 then q8–12 weeks; Vabysmo 6 mg q4 weeks x4 then q8/12/16 weeks (some patients may require monthly dosing after first 4 doses); Eylea HD 8 mg induction then 8 mg q8–16 weeks.
These are agent examples; use the specific agent entry for exact dosing intervals and any initial vs maintenance separation.
Prior trial / response prerequisites: When specified, provider must document prior trial, failure, intolerance, or prior clinical response per agent: e.g., pegaptanib (Macugen) used when bevacizumab has failed or is contraindicated; Susvimo (ranibizumab implant) requires prior response to at least two intravitreal injections of the same VEGF inhibitor within the last 6 months; some agents indicate use when bevacizumab has failed or is contraindicated. Step protocol is not mandated for Medicare members where noted.
Document trials, failures, or responses in authorization/medical record.
Ocriplasmin (Jetrea) specific criteria: Member > 18 years of age AND OCT shows vitreomacular adhesion within 6 mm of the fovea with elevation of the posterior vitreous cortex AND best‑corrected visual acuity < 20/25 in the eye to be treated.
Repeat intravitreal ocriplasmin injections are considered experimental/investigational (not covered).
Fluocinolone intravitreal implants (Retisert, Iluvien, Yutiq): Covered for indicated uses (for example chronic non‑infectious posterior uveitis or DME per agent labeling) with product‑specific quantity limits: Retisert one implant per eye every 30 months; Yutiq one implant per eye every 36 months; Iluvien one implant per eye every 36 months for DME when prior corticosteroid did not cause clinically significant IOP rise.
Follow agent label and quantity limits documented in policy.
Dexamethasone intravitreal implant/suspension/insert (Ozurdex, Dexycu, Dextenza): Ozurdex covered for macular edema following BRVO or CRVO and for non‑infectious posterior uveitis (one implant per eye every 8 weeks) and for DME (one implant per eye every 16 weeks). Dexycu intraocular suspension covered for postoperative inflammation in members >18 when topical steroid drops failed or are contraindicated. Dextenza intracanalicular insert covered for postoperative pain when topical steroid drops failed or are contraindicated.
Document prior topical therapy failure or contraindication for Dexycu/Dextenza where required.
Bimatoprost intracameral implant (Durysta) prerequisites: Member > 18 years of age AND reduction of intraocular pressure (IOP) is the indication (open‑angle glaucoma or ocular hypertension) AND member has had trial and failure or intolerance to at least two topical IOP agents with different mechanisms (one must be a prostaglandin analog) AND the affected eye has not previously received Durysta.
Step protocol not mandated for Medicare members where noted; document prior topical therapy trials.