This version of the policy will become effective 10/30/2017.
This policy was updated to include a new FDA-labeled indication for Lucentis® for the treatment of non-proliferative and proliferative diabetic retinopathy in individuals with or without diabetic macular edema.
When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
J2503 Injection, pegaptanib sodium, 0.3 mg
J2778 Injection, ranibizumab, 0.1 mg
Policy: 07.13.06k:Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
Policy: 08.00.15e:Off-label Coverage for Prescription Drugs and/or Biologics
Policy: 08.00.66m:Bevacizumab (Avastin®) and Related Biosimilars