ModifiedUnitedHealthcarePolicy CSOH2O25D0042.G

Ophthalmologic Vascular Endothelial Growth Factor (VEGF) Inhibitors (for Ohio Only)

Clinical coverage and medical necessity criteria for selected intravitreal VEGF and dual VEGF–Ang-2 inhibitors for members in Ohio; applies to specialty pharmacy medications administered intravitreally.

Policy Summary

PayerUnitedHealthcare

PolicyOphthalmologic Vascular Endothelial Growth Factor (VEGF) Inhibitors (for Ohio Only)

Policy CodePolicy CSOH2O25D0042.G

Change TypeMaterial coverage revisionsICD-10 code updates

Effective DateAug 1, 2025

Next Review Date

Key ActionObtain prior authorization and document compliance with the current InterQual Intravitreal criteria; for Susvimo in DME, confirm prior response to ≥2 intravitreal VEGF injections.

SourceLink

POLICY UPDATE CHANGES

Added language that Susvimo (ranibizumab) is proven and medically necessary for treatment of diabetic macular edema (DME) in patients who previously responded to two intravitreal VEGF injections.

Replaced coverage guidelines with language indicating certain ophthalmologic VEGF inhibitors are proven and medically necessary when criteria of the InterQual CP: Specialty Rx Non-Oncology: Intravitreal are met.

Updated list of applicable ICD-10 diagnosis codes for HCPCS code J2779 — numerous diabetes-related and retinal diagnosis codes were added.

Updated supporting information including Clinical Evidence, FDA, and References to reflect current information.

12maximum intravitreal doses per year per eye

Susvimo addedSpecific drug coverage change

Multiple

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HCPCS/HCPCS-like drug codes listed

20+ICD-10 diagnosis codes listed

Coverage and Medical Necessity Criteria

Applicable Codes and Code Mappings

Intravitreal HCPCS / J-codes (listed agents)HCPCSCovered

J0177	Injection, aflibercept; mg (Eylea / Eylea HD)
J0178	Injection, aflibercept; 1 mg (Eylea)
J0179	Injection, brolucizumab-dbll; mg (Beovu)
J2777	Injection, faricimab-svoa (Vabysmo)
J2778	Injection, ranibizumab; 0.1 mg (Lucentis)
J2779	Injection, ranibizumab, via intravitreal implant (Susvimo); 0.1 mg
J9035	Injection, bevacizumab; 10 mg (Avastin)
Q5124	Injection, ranibizumab-nuna, biosimilar; 0.1 mg (Byooviz)
Q5128	Injection, ranibizumab-eqrn, biosimilar; 0.1 mg (Cimerli)
Q5147	Injection, aflibercept-ayyh, biosimilar; 1 mg (Pavblu)

Sample ICD-10 — Diabetes-related retinal diagnoses (examples)ICD-10

E08.311	Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema
E08.3211	Diabetes due to underlying condition with mild NPDR with macular edema, right eye
E08.3212	... left eye
E08.3213	... bilateral
E08.3219	... unspecified eye

Comprehensive ICD-10 Codes mapped to intravitreal HCPCS (consolidated list)ICD-10Covered

E08.3531	Diabetes due to underlying condition w/ proliferative DR with TRD not involving macula, right eye
E08.3532	... left eye
E08.3533	... bilateral
E08.3539	... unspecified eye
E08.3541	proliferative DR w/ combined TRD and RRD; right eye
E08.3542	... left eye
E08.3543	... bilateral
E08.3549	... unspecified eye
E08.3551	stable proliferative DR, right eye
E08.3552	... left eye

1–10 of 65

1/7

Additional ICD-10 codes (Diabetes Type 1 / Type 2 / Other specified) mapped to intravitreal HCPCSICD-10Covered

E10.3413	Type 1 diabetes with severe NPDR with macular edema, bilateral
E10.3419	... unspecified eye
E10.3511	Type 1 diabetes with proliferative DR with macular edema, right eye
E10.3512	... left eye
E10.3513	... bilateral
E10.3519	... unspecified eye
E10.3521	proliferative DR w/ TRD involving macula, right eye
E10.3522	... left eye
E10.3523	... bilateral
E10.3529	... unspecified eye

1–10 of 29

1/3

Additional ICD-10 — Type 2, Other, and retinal vascular codes (continued)ICD-10Covered

E11.311	Type 2 diabetes with unspecified DR with macular edema
E11.3212	Type 2 diabetes with mild NPDR with macular edema, left eye
E11.3213	... bilateral
E11.3219	... unspecified eye
E11.3291	mild NPDR without macular edema, right eye
E11.3292	... left eye
E11.3293	... bilateral
E11.3299	... unspecified eye
E11.3311	moderate NPDR with macular edema, right eye
E11.3312	... left eye

1–10 of 20

1/2

Other specified diabetes and retinal / RVO / AMD related ICD-10 codesICD-10Covered

E13.3291	other specified diabetes mild NPDR without macular edema, right eye
E13.3292	... left eye
E13.3293	... bilateral
E13.3299	... unspecified eye
E13.3311	other specified diabetes moderate NPDR with macular edema, right eye
E13.3312	... left eye
E13.3313	... bilateral
E13.3319	... unspecified eye
E13.3411	other specified diabetes severe NPDR with macular edema, right eye
E13.3412	... left eye

1–10 of 17

1/2

Retinal vascular / AMD / other ophthalmic ICD-10 codes (continued)ICD-10Covered

H34.8191	Central retinal vein occlusion, unspecified eye, with retinal neovascularization
H34.8311	Tributary retinal vein occlusion, right eye, with retinal neovascularization
H34.8331	Tributary retinal vein occlusion, bilateral, with retinal neovascularization
H34.8391	Tributary retinal vein occlusion, unspecified eye, with retinal neovascularization
H35.3231	Exudative AMD, bilateral, with active choroidal neovascularization
H35.3232	Exudative AMD, bilateral, with inactive choroidal neovascularization
H35.3233	Exudative AMD, bilateral, with inactive scar
H35.3213	Exudative AMD, right eye, with inactive scar
H35.3223	Exudative AMD, left eye, with inactive scar

Additional ophthalmic ICD-10 codes (macular degeneration, cystoid macular degeneration, myopic CNV)ICD-10Covered

H35.351	Cystoid macular degeneration, right eye
H35.352	... left eye
H35.353	... bilateral
H40.89	Other specified glaucoma
H44.2A1	Degenerative myopia with choroidal neovascularization, right
H44.2A2	... left
H44.2A3	... bilateral
H44.2A9	... unspecified eye

Referenced products / FDA indications (summary)mixed

Eylea HD (aflibercept)	Indicated for neovascular AMD, DME, and DR
Pavblu (aflibercept-ayyh)	Indicated for neovascular AMD, macular edema following RVO, DME, and DR
Susvimo (ranibizumab)	Indicated for neovascular AMD and DME in patients who previously responded to >=2 intravitreal VEGF injections

Prior Authorization, Documentation, and Billing Instructions

Prior Authorization

Prior authorization required for listed HCPCS/Q-codes

Prior authorization/medical necessity review applies to intravitreal injections of the listed HCPCS and Q-codes for ophthalmologic VEGF and related agents; benefit coverage is determined by clinical criteria and Ohio rules.

Codes listed include J0177, J0178, J0179, J2777, J2778, J2779, J9035, Q5124, Q5128, Q5147.

Prior Authorization

Ensure diagnosis maps to HCPCS when requesting prior auth

Many ICD-10 diagnosis codes in the Applicable Codes section are mapped to specific HCPCS drug codes (for example J0177, J2779, Q5147); ensure the member’s diagnosis code is one of the listed codes when initiating a prior authorization request.

Examples in the policy show E08.3511–E08.3519 mapped to J2779 and Q5147.

Prior Authorization

Clinical Background and Scope

Intravitreal vascular endothelial growth factor (VEGF) inhibitors and the newer dual VEGF–Ang‑2 inhibitor are therapies used to treat retinal vascular diseases including neovascular age‑related macular degeneration (nAMD), diabetic macular edema (DME) and diabetic retinopathy (DR), and macular edema secondary to retinal vein occlusion (RVO). Product labeling and clinical trial evidence support these indications; this policy identifies specific agents and references InterQual clinical criteria and FDA indications to inform medical necessity determinations. Providers should note that dosing and continuation decisions are subject to the policy’s limits (for example, a maximum of 12 intravitreal doses per year per eye) and to the InterQual CP: Specialty Rx Non‑Oncology: Intravitreal criteria where referenced.

Definitions and Key Terms

VEGF inhibitor / dual VEGF–Ang-2 inhibitor — inv-51

DefinitionMedications administered by intravitreal injection that inhibit vascular endothelial growth factor (VEGF) — includes agents listed in policy such as aflibercept, ranibizumab, bevacizumab, brolucizumab and one dual VEGF–Ang‑2 inhibitor (faricimab).

Included agents (examples)Beovue (brolucizumab-dbll), Avastin (bevacizumab), Byooviz (ranibizumab-nuna), Eylea (aflibercept), Cimerlie (ranibizumab-eqrn), Eylea HD, Pavblu (aflibercept-ayyh), Lucentis (ranibizumab), Susvimo (ranibizumab), Vabysmo (faricimab-svoa).

Route of administrationIntravitreal injection (direct injection into the vitreous of the eye).

Dose limit definition — inv-52

Policy dose limitMaximum of 12 intravitreal doses per year per eye for initial and continuation of therapy.

Applies regardless of diagnosis

Policy Summary

PayerUnitedHealthcare

PolicyOphthalmologic Vascular Endothelial Growth Factor (VEGF) Inhibitors (for Ohio Only)

Policy CodePolicy CSOH2O25D0042.G

Change TypeMaterial coverage revisionsICD-10 code updates

Effective DateAug 1, 2025

Next Review Date

Key ActionObtain prior authorization and document compliance with the current InterQual Intravitreal criteria; for Susvimo in DME, confirm prior response to ≥2 intravitreal VEGF injections.

SourceLink

On This Page

Confirm ICD-10 mapping for J2779 prior authorization

HCPCS J2779 is shown as applicable to multiple ICD-10 diagnoses in the Applicable Codes tables; when using J2779 verify and document the mapped ICD-10 code(s) to support prior authorization and claims.

Multiple diabetes-related ICD-10 codes (e.g., E09.37X2, E09.37X3) are marked as applying to J2779 in the mapping.

Prior Authorization

Tie prior auth to HCPCS drug codes on request

Prior authorization requirements are tied to HCPCS drug codes referenced in the policy (for example J0177 and J2779); providers must ensure the claim’s HCPCS code corresponds to an applicable ICD-10 diagnosis from the policy lists.

Document the HCPCS code billed (e.g., J0177, J2779) and the mapped ICD-10 diagnosis on the prior authorization and claim.

Prior Authorization

Prior authorization required for applicable HCPCS J-codes

Prior authorization is required when billing the applicable HCPCS J-codes listed for ocular anti‑VEGF agents; submitted ICD-10 diagnosis codes must match one of the policy’s mapped conditions to support approval.

Verify that the billed J-code corresponds to a listed diagnosis (policy contains mappings for J0177, J2779 and others).

Prior Authorization

Prior authorization tied to InterQual intravitreal criteria

Coverage and prior authorization determinations for the referenced intravitreal agents are made when the member meets the medical necessity criteria in the current InterQual CP: Specialty Rx Non‑Oncology: Intravitreal guideline; prior authorization may reference InterQual findings.

Providers must use the current release of the InterQual intravitreal criteria for clinical entry and continuation decisions.

Prior Authorization

Avastin coverage follows InterQual criteria

Avastin (bevacizumab) medical necessity determinations reference and follow the current InterQual CP: Specialty Rx Non‑Oncology bevacizumab (Avastin) intravitreal criteria.

For Avastin, refer to the current InterQual guideline for required clinical sequencing and criteria.

Step Therapy

Document ≥2 prior responsive intravitreal VEGF injections for Susvimo (DME)

For Susvimo used in diabetic macular edema (DME), document that the patient previously responded to at least two intravitreal injections of a VEGF inhibitor before requesting coverage or prior authorization.

Policy change explicitly added Susvimo for DME in patients who previously responded to ≥2 intravitreal VEGF injections.

Documentation Required

Document compliance with InterQual intravitreal clinical criteria

Medical necessity determinations for listed agents reference the current InterQual CP: Specialty Rx Non‑Oncology: Intravitreal criteria; providers should document indication and show compliance with InterQual criteria when submitting requests.

Include InterQual-relevant clinical findings in the prior authorization submission where applicable.

Documentation Required

Document the mapped ICD-10 diagnosis when billing J2779

When billing HCPCS J2779, document the specific ICD-10 diagnosis code from the policy’s Applicable Codes list that supports use of that HCPCS code.

Examples in the mapping show J2779 applied to numerous diabetes-related retinopathy codes; include the exact code for the treated eye.

Documentation Required

Include the treated‑eye ICD‑10‑CM code on claims and prior auths

Claims and prior authorization requests must include the specific ICD‑10‑CM diagnosis code that applies to the treated eye (right, left, bilateral, or unspecified) when billing intravitreal anti‑VEGF HCPCS codes.

Use the eye‑specific ICD‑10 code (e.g., E10.3211 for right eye) from the policy’s lists on the claim and PA documentation.

Billing Rule

Submit claims with the ICD‑10 code mapped to the billed HCPCS/J‑code

Ensure claims include the relevant ICD‑10 diagnosis code mapped to the HCPCS/J‑code listed in the policy; absence of an applicable mapped diagnosis may lead to denial or downcoding.

The Applicable Codes section shows multiple ICD‑10-to‑HCPCS mappings—confirm the correct pair before submission.

Documentation Required

Reference the current InterQual intravitreal release in submissions

Reference and document compliance with the current release of InterQual CP: Specialty Rx Non‑Oncology: Intravitreal clinical coverage criteria when submitting prior authorization or medical necessity requests for the listed agents.

Policy explicitly instructs providers to refer to the current InterQual release for clinical entry and continuation criteria.

Denial Risk

Do not exceed 12 intravitreal doses/year/eye without justification

Requests exceeding 12 intravitreal doses per year per eye may be evaluated against the policy dosing limit and could be denied or require additional justification.

The policy limit is a maximum of 12 doses per year per eye for initial and continuation of therapy.

Note

Verify jurisdiction (policy applies to Ohio)

This policy applies to members in Ohio; requests for members outside Ohio may be subject to other jurisdictional rules and could be non‑applicable to this policy.

Verify the member’s state and applicable benefit rules before submitting a prior authorization under this policy.

Denial Risk

Use only listed ICD‑10 codes mapped to J2779 to avoid denials

Claims may be denied if billed with diagnosis codes that are not listed as applicable to the HCPCS/J2779 mappings in the policy; confirm the diagnosis code is among those enumerated.

The Applicable Codes tables show specific ICD‑10 codes mapped to J2779; unlisted codes risk denial.

Billing Rule

Confirm ICD‑10 applicability to billed HCPCS codes

Claims are evaluated against the policy’s listed ICD‑10 codes to determine applicability to HCPCS drug codes; absence of an applicable diagnosis code on the claim may affect coverage determination.

Confirm the ICD‑10 diagnosis code in the Applicable Codes section corresponds to the billed HCPCS before submission.

Denial Risk

Do not rely solely on FDA approval for coverage

FDA approval is provided for informational purposes only; FDA approval alone does not establish coverage—requests relying solely on FDA approval without meeting policy criteria may be denied.

Policy states FDA approval is not a basis for coverage decisions; follow InterQual and applicable benefit rules.

Denial Risk

Non‑compliant requests may be denied under InterQual standards

Requests that do not meet the referenced InterQual CP: Specialty Rx Non‑Oncology: Intravitreal medical necessity criteria for the listed ophthalmologic VEGF inhibitors may be denied; include supporting clinical documentation or appeal if criteria are not met.

Providers should document relevant clinical findings that demonstrate compliance with InterQual criteria for the requested agent.

The 12 doses/year/eye limit applies to all indications covered by this policy.

Denial riskRequests exceeding 12 intravitreal doses per year per eye may be evaluated against the policy limit and could be denied.

Diabetic macular edema and diabetic retinopathy ICD-10 codes — inv-53

Examples of ICD-10 codesIncludes numerous diabetes-related retinal codes such as E08.311, E09.3211, E10.3211, E11.3211 (diabetes with nonproliferative diabetic retinopathy with macular edema), and many others listed in the policy mappings for intravitreal agents.

Use in claimsProviders must document the specific ICD-10-CM diagnosis code from the listed codes to support billing for applicable HCPCS/J-codes.

ScopeList contains Type 1, Type 2, drug/chemical-induced and other-specified diabetes mellitus codes with various retinopathy and macular edema statuses.

Diabetic macular edema resolved codes — inv-54

Resolution codesDiabetic macular edema resolved following treatment is represented by codes E11.37X1–E11.37X9 (and analogous E13 and other diabetes category codes such as E08.37X1–E08.37X9, E09.37X1–E09.37X9) as listed in the policy.

Mapping noteThese 'resolved following treatment' codes are included in the policy's ICD-10-to-HCPCS mappings for intravitreal agent applicability.

ExamplesE11.37X1 (DME resolved, right eye), E11.37X2 (left eye), E11.37X3 (bilateral), E11.37X9 (unspecified eye).

VEGF term definition — inv-55

DefinitionVascular endothelial growth factor (VEGF) is a protein that stimulates growth, proliferation and survival of vascular endothelial cells, increases vascular permeability, and is implicated in pathological ocular neovascularization and blood–retinal barrier breakdown.

Role in diseaseVEGF contributes to angiogenesis and increased vascular permeability relevant to retinal vascular diseases such as DME, DR, RVO and neovascular AMD.

Aflibercept / Eylea HD — inv-56

ProductAflibercept (Eylea HD) — an anti‑VEGF agent referenced in the policy as indicated for neovascular (wet) age‑related macular degeneration (AMD), diabetic macular edema (DME) and diabetic retinopathy (DR).

Indications notedPolicy cites Eylea HD as proven and medically necessary for nAMD, DME and DR per product labeling and referenced clinical evidence.

Susvimo — inv-57

DescriptionSusvimo is an implanted ranibizumab delivery system (ranibizumab via intravitreal implant) referenced in the policy.

Indication notePolicy states Susvimo is indicated for neovascular AMD and for DME in patients who previously responded to at least two intravitreal VEGF inhibitor injections; this prior‑response requirement was added in the 08/01/2025 revision.

Aflibercept products (Eylea, Pavblu) — inv-58

ProductsAflibercept formulations referenced include Eylea (aflibercept), Eylea HD and Pavblu (aflibercept-ayyh).

IndicationsPolicy notes these aflibercept products are indicated for neovascular AMD; Eylea HD and Pavblu are indicated for DME and DR as specified by product labeling; Pavblu also lists macular edema following RVO where noted.

Clinical contextCoverage aligns with FDA‑indicated uses and clinical trial evidence cited in the policy for these products.