Prior authorization required; 12‑month initial limit

Prior authorization is required for Susvimo; initial authorizations will be for no longer than 12 months and continuation/reauthorization requires documentation of a positive clinical response with dosing per FDA-approved labeling.

• Initial authorization limited to no longer than 12 months.
• Reauthorization requires documentation of positive clinical response and dosing consistent with FDA label.

ICD‑10 code listing only — no PA directive in these chunks

This section of the document provides ICD‑10 diagnosis code listings only and does not state prior authorization directives in the provided chunks.

Confirm indication and member benefit plan; verify prior VEGF response

Verify the patient meets the FDA‑indicated diagnosis and that the member’s benefit plan permits coverage; confirm the patient has the required prior response to VEGF inhibitor therapy before approving Susvimo.

• Reference the member specific benefit plan document to determine coverage applicability.
• Confirm the patient meets indication criteria and prior VEGF response per policy and FDA labeling.

Prior VEGF inhibitor response required (≥2 intravitreal injections)

Documented prior response to at least two intravitreal injections of a VEGF inhibitor is required for FDA‑indicated use and for coverage consideration.

• Examples of VEGF inhibitors listed in policy: bevacizumab, aflibercept, ranibizumab, aflibercept-ayyh, faricimab.
• Requirement applies to AMD, DME, and DR indications per FDA labeling.

Document prior intravitreal VEGF therapy and response

For FDA‑labeled indications, document prior intravitreal VEGF therapy and that the patient previously responded to at least two intravitreal injections of a VEGF inhibitor medication.

• Policy lists the FDA indications (AMD, DME, DR) each requiring prior response to ≥2 intravitreal VEGF injections.
• Include prior treatment details in the request documentation.

Include diagnosis and documented response to ≥2 prior intravitreal injections

Documentation submitted with an authorization request must show the diagnosis (neovascular AMD, DME, or DR) and that the patient previously responded to at least two intravitreal injections of a VEGF inhibitor; dosing intent must follow FDA labeling.

• State the diagnosis and laterality as applicable using the appropriate ICD‑10 code.
• Provide records of prior anti‑VEGF injections and clinical response.
• Specify planned dosing consistent with FDA‑approved labeling.

Reference member benefit plan and document treatment details

When requesting coverage, reference the member specific benefit plan and any applicable federal or state mandates; document the treatment indication, prior VEGF responses, and member plan applicability.

• Member specific benefit plan governs in case of conflicts with this policy.
• Include documentation of prior VEGF treatment and response and note plan applicability (Commercial, Individual Exchange, or mandates).

Denial risk if no qualifying diagnosis or insufficient prior‑VEGF documentation

Requests that do not document a qualifying diagnosis (neovascular AMD, DME, or diabetic retinopathy) or lack documentation of prior response to at least two intravitreal VEGF inhibitor injections may be denied.

• Absence of documented prior response to ≥2 intravitreal VEGF injections is a risk for coverage denial.
• Lack of an applicable diagnosis per policy (AMD, DME, DR) may result in denial.

No authorization/denial instructions in this segment

This segment contains only diagnosis code listings and does not include explicit prior authorization or denial instructions in the provided chunks.

Apply prior‑response requirement for non‑meeting indications

Use this prior‑response requirement when evaluating indications that do not meet the FDA‑described prior response standard; patients without documented response to at least two intravitreal VEGF injections may not meet coverage criteria.

• Apply denial risk for indications lacking the ≥2 prior‑injection documented response required by FDA labeling.