CurrentUnitedHealthcarePolicy 2025D0138B

Susvimo (ranibizumab intravitreal implant) coverage

Clinical coverage criteria for Susvimo (ranibizumab intravitreal implant) for UnitedHealthcare Commercial members; specifies diagnoses, prior treatment response requirement, dosing conformity to FDA labeling, and authorization durations.

Policy Summary

PayerUnitedHealthcare

PolicySusvimo (ranibizumab intravitreal implant) coverage

Policy CodePolicy 2025D0138B

Change TypeIndications and code additions (DR and ICD-10 expansion)

Effective Date09/01/2025

Next Review DateN/A

Key ActionObtain prior authorization documenting at least two prior intravitreal VEGF injections with evidence of response and follow FDA‑approved dosing; initial and reauthorization approvals are limited to up to 12 months.

SourceLink

POLICY UPDATE CHANGES

Revised list of applicable diagnoses for which Susvimo is proven and medically necessary; added diabetic retinopathy (DR).

Added numerous ICD-10 diagnosis codes (E08.*, E09.*, E10.*, E11.*, E13.* series) to applicable codes list.

Updated clinical evidence, FDA, and references sections to reflect most current information (May 2025 package insert and trial results).

3Eligible diagnoses listed

>=2Required prior intravitreal VEGF injections (response to)

12Maximum initial authorization duration

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