Notification

Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists (e.g., ranibizumab [Lucentis®], pegaptanib sodium [Macugen®], aflibercept [Eylea®], and related biosimilars)


Notification Issue Date: 09/29/2017

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.



Medical Policy Bulletin


Title:Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists (e.g., ranibizumab [Lucentis®], pegaptanib sodium [Macugen®], aflibercept [Eylea®], and related biosimilars)

Policy #:08.00.74l

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

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.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

MEDICALLY NECESSARY

RANIBIZUMAB (LUCENTIS®) AND RELATED BIOSIMILARS
The intravitreal injection of vascular endothelial growth factor (VEGF) antagonist ranibizumab (Lucentis®) and related biosimilars are considered medically necessary and, therefore, covered for individuals who have the following conditions:
  • Neovascular (wet or exudative) age-related macular degeneration (AMD)
  • Macular edema following retinal vein occlusion
  • Diabetic macular edema (DME)
  • Non-proliferative and proliferative diabetic retinopathy
  • Choroidal neovascularization due to angioid streaks, central serous chorioretinopathy, choroidal rupture or trauma, idiopathic choroidal neovascularization, multifocal choroiditis, pathologic myopia, presumed ocular histoplasmosis syndrome, and uveitis

PEGAPTANIB SODIUM (MACUGEN®) AND RELATED BIOSIMILARS
The intravitreal injection of vascular endothelial growth factor (VEGF) antagonist pegaptanib sodium (Macugen®) and related biosimilars are considered medically necessary and, therefore, covered for individuals who have the following conditions:
  • Neovascular (wet or exudative) age-related macular degeneration (AMD)
  • Diabetic macular edema

AFLIBERCEPT (EYLEA®) AND RELATED BIOSIMILARS
The intravitreal injection of vascular endothelial growth factor (VEGF) antagonist aflibercept (Eylea®) and related biosimilars are considered medically necessary and, therefore, covered for individuals who have the following conditions:
  • Neovascular (wet or exudative) age-related macular degeneration (AMD)
  • Macular edema following retinal vein occlusion (RVO)
  • Diabetic macular edema
  • Non-proliferative and proliferative diabetic retinopathy in individuals with diabetic macular edema

EXPERIMENTAL/INVESTIGATIONAL

All other uses of ranibizumab (Lucentis®), pegaptanib sodium (Macugen®), aflibercept (Eylea®) and related biosimilars are considered experimental/investigational and, therefore, not covered unless the indication is supported as an accepted off-label use, as defined in the medical policy on off-label coverage for prescription drugs and biologics.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the drug.
Guidelines

ADMINISTRATION GUIDELINES FROM THE PRODUCT'S PACKAGE INSERT

RANIBIZUMAB (LUCENTIS®)
Ranibizumab (Lucentis®) is supplied in a single-dose vial or single-dose prefilled syringe and is administered only by ophthalmic intravitreal injection, no more than once monthly per affected eye for treatment of wet age-related macular degeneration (AMD), macular edema following retinal vein occlusion, diabetic macular edema, and diabetic retinopathy.

Although less effective, treatment for AMD may begin with 3 monthly doses followed by less frequent dosing. In the 9 months after the 3 initial monthly doses, less frequent dosing with 4-5 doses on average is expected to maintain visual acuity while monthly dosing may be expected to result in an additional average 1-2 letter gain of visual acuity. Individuals should be evaluated regularly.

Although less effective, treatment for AMD may be reduced to one injection every 3 months after the first 4 injections if monthly injections are not feasible. Compared to continued monthly dosing, dosing every 3 months will lead to an approximate 5-letter (1-line) loss of visual acuity benefit, on average, over the following nine months. Individuals should be evaluated regularly.

Monthly dosing for up to three months is the recommendation for the treatment of Myopic Choroidal Neovascularization (mCNV); although individuals may be retreated, if needed.

PEGAPTANIB SODIUM (MACUGEN®)
Pegaptanib sodium (Macugen®) is supplied in a single-dose vial and is administered only by ophthalmic intravitreal injection, once every 6 weeks per affected eye. The safety and efficacy of pegaptanib sodium (Macugen®) administered to both eyes concurrently have not been studied.

AFLIBERCEPT (EYLEA®)
Aflibercept (Eylea®) is supplied as a single-dose vial and is administered only by ophthalmic intravitreal injection as follows:
  • Wet AMD: every 4 weeks (monthly) for the first 3 months, followed by one intravitreal injection every 8 weeks. Additional efficacy was not demonstrated in most individuals when dosing every 4 weeks compared to every 8 weeks; however, some individuals may need dosing every 4 weeks after the first 3 months.
  • Diabetic macular edema and diabetic retinopathy in individuals with diabetic macular edema: every 4 weeks (monthly) for the first 5 months, followed by one intravitreal injection every 8 weeks. Additional efficacy was not demonstrated in most individuals when dosing every 4 weeks compared to every 8 weeks; however, some individuals may need dosing every 4 weeks after the first 20 weeks (5 months).
  • Macular edema following retinal vein occlusion (RVO): every 4 weeks

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, the intravitreal injection of ranibizumab (Lucentis®), pegaptanib sodium (Macugen®), aflibercept (Eylea®) or related biosimilars are covered under the medical benefits of the Company’s products when the medical necessity criteria listed in the medical policy are met.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

Ranibizumab (Lucentis®) was approved by the FDA on June 30, 2006, for the treatment of neovascular (wet) age-related macular degeneration. Supplemental approvals for ranibizumab (Lucentis®) have since been issued by the FDA for macular edema following retinal vein occlusion, diabetic macular edema, diabetic retinopathy and myopic choroidal neovascularization (mCNV).

Pegaptanib sodium (Macugen®) was approved by the FDA on December 17, 2004, for the treatment of neovascular (wet) age-related macular degeneration.

Aflibercept (Eylea®) was approved by the FDA on November 18, 2011 for treatment of neovascular (wet) age-related macular degeneration. Supplemental approvals for aflibercept (Eylea®) has since been issued by the FDA for macular edema following central and branch retinal vein occlusion (RVO), and for diabetic macular edema.

The safety and effectiveness of aflibercept (Eylea®), pegaptanib sodium (Macugen®), and ranibizumab (Lucentis®) have not been established in the pediatric population.

Description

Vascular endothelial growth factor (VEGF) is a secreted protein that selectively binds and activates its receptors, which are located primarily on the surface of vascular endothelial cells. VEGF stimulates new blood vessel formation. Overexpression of VEGF can induce abnormal neovascularization and increase vascular permeability and inflammation.

Neovascularization results in the growth of abnormal blood vessels behind the retina and contributes to the progression of neovascular (wet) age-related macular degeneration (AMD), also known as exudative AMD. Wet AMD occurs when the abnormal blood vessels under the macula leak blood and fluid, leading to vision loss.

Other ocular conditions where VEGF plays a role includes retinal vein occlusion (RVO) where the normal blood flow through a retinal vein becomes blocked, causing edema and hemorrhaging in the retina that can lead to vision loss. RVO is classified according to whether the central retinal vein (CRVO) or one of its branches is obstructed. Diabetic macular edema (DME) is a condition associated with diabetes and causes blurred vision, severe vision loss, and sometimes blindness. Diabetic retinopathy may occur with or without DME and is classified as non-proliferative or proliferative, depending on the severity of the disease. Choroidal neovascularization occurs when abnormal blood vessels begin growing in the choroid (the area beneath the retina) and move into sub-retinal space and leak blood and fluid, leading to vision loss.

Pegaptanib sodium (Macugen®) is a selective VEGF antagonist that received FDA approval in 2004 for the treatment of neovascular (wet) age-related macular degeneration. The mechanism of action for the drug is the suppression of pathological neovascularization by inhibiting a VEGF isoform called extracellular VEGF-165 from binding to its VEGF receptors. Pegaptanib sodium (Macugen®) is administered via ophthalmic intravitreal injection.

Ranibizumab (Lucentis®) is a vascular endothelial growth factor A (VEGF-A) antagonist that received FDA approval in 2006 for the treatment of neovascular (wet) AMD. Ranibizumab (Lucentis®) works by binding to and inhibiting the action of VEGF-A, a substance that binds to certain cells to stimulate new blood vessel formation and growth (e.g., angiogenesis, neovascularization). When VEGF-A binds to ranibizumab (Lucentis®), it cannot stimulate neovascularization. Ranibizumab (Lucentis®) is also administered via ophthalmic intravitreal injection. Ranibizumab (Lucentis®) received supplemental approvals from the FDA in June 2010 for use in the treatment of macular edema following retinal vein occlusion (RVO) and in August 2012 for use in the treatment of DME. In February 2015, ranibizumab (Lucentis®) received FDA approval for use in the treatment of diabetic retinopathy in individuals with DME; in April 2017, the approval was modified to include those without DME. Also, in January 2017, Ranibizumab (Lucentis®) was FDA approved for the treatment of Myopic Choroidal Neovascularization (mCNV).

Aflibercept (Eylea®) is another VEGF antagonist administered via ophthalmic intravitreal injection that received FDA approval in 2011 for the treatment of neovascular (wet) AMD. Aflibercept (Eylea®) acts as a soluble decoy receptor that binds VEGF-A and placental growth factor (PIGF), a second growth factor that initiates the formation of new blood vessels. Aflibercept (Eylea®) received supplemental approvals from the FDA in September 2012 for use in the treatment of macular edema following central retinal vein occlusion (CRVO), in July 2014 for use in the treatment of diabetic macular edema, in October 2014 for use in the treatment of macular edema following branch retinal vein occlusion, and in March 2015 for use in the treatment of diabetic retinopathy in individuals with diabetic macular edema.

OFF-LABEL INDICATIONS

There may be additional indications contained in the Policy section of this document due to evaluation of criteria highlighted in the Company’s off-label policy, and/or review of clinical guidelines issued by leading professional organizations and government entities.
References


American Academy of Ophthalmology Retina/Vitreous Panel. Preferred practice pattern guidelines. Diabetic retinopathy. San Francisco, CA; 2016. Available at: https://www.aao.org/preferred-practice-pattern/diabetic-retinopathy-ppp-updated-2016 . Accessed July 18, 2017.

American Hospital Formulary Service (AHFS). Aflibercept. Drug Information 2017. [Lexicomp Online Web site]. 03/31/16. Available at: http://online.lexi.com/lco/action/home [via subscription only]. Accessed June 9, 2017.

American Hospital Formulary Service (AHFS). Pegaptanib sodium. Drug Information 2017. [Lexicomp Online Web site]. January 1, 2009. Available at: http://online.lexi.com/lco/action/home [via subscription only]. Accessed June 2, 2017.

American Hospital Formulary Service (AHFS). Ranibizumab. Drug Information 2017. [Lexicomp Online Web site]. 06/30/16. Available at: http://online.lexi.com/lco/action/home [via subscription only]. Accessed June 9, 2017.

Artunay O, Yuzbasioglu E, Rasier R, et al. Combination treatment with intravitreal injection of ranibizumab and reduced fluence photodynamic therapy for choroidal neovascularization secondary to angioid streaks: preliminary clinical results of 12-month follow-up. Retina. 2011;31(7):1279-86.

BlueCross BlueShield Association (BCBSA), Technology Evaluation Center (TEC). 9.03.27 Intravitreal Angiogenesis Inhibitors for Retinal Vascular Conditions. TEC Assessment Program. Chicago, IL: BCBSA; February 27, 2013.

Carneiro AM, Silva RM, Veludo MJ, et al. Ranibizumab treatment for choroidal neovascularization from causes other than age-related macular degeneration and pathological myopia. Ophthalmologica. 2011;225(2):81-8.

Chakravarthy U, Harding SP, Rogers CA, et al; IVAN study investigators. Alternative treatments to inhibit VEGF in age-related choroidal neovascularisation: 2-year findings of the IVAN randomised controlled trial. Lancet. 2013;382(9900):1258-67.

Cunningham ET Jr, Adamis AP, Altaweel M, et al; Macugen Diabetic Retinopathy Study Group. A phase II randomized double-masked trial of pegaptanib, an anti-vascular endothelial growth factor aptamer, for diabetic macular edema. Ophthalmology. 2005;112(10):1747-57.

Do DV, Nguyen QD, Boyer D, et al; da Vinci Study Group. One-year outcomes of the da Vinci Study of VEGF Trap-Eye in eyes with diabetic macular edema. Ophthalmology. 2012;119(8):1658-65.

Do DV, Schmidt-Erfurth U, Gonzalez VH, et al. The DA VINCI Study: phase 2 primary results of VEGF Trap-Eye in patients with diabetic macular edema. Ophthalmology. 2011;118(9):1819-26.

Elsevier Gold Standard’s Clinical Pharmacology Compendium.Aflibercept. 03/21/17. [Clinical Pharmacology Web site]. Available at: https://www.clinicalkey.com/pharmacology/ [via subscription only]. Accessed June 9, 2017.

Elsevier Gold Standard’s Clinical Pharmacology Compendium.Pegaptanib. 03/21/17. [Clinical Pharmacology Web site]. Available at: https://www.clinicalkey.com/pharmacology/ [via subscription only]. Accessed June 2, 2017.

Elsevier Gold Standard’s Clinical Pharmacology Compendium.Ranibizumab. 04/18/17. [Clinical Pharmacology Web site]. Available at: https://www.clinicalkey.com/pharmacology/ [via subscription only]. Accessed June 9, 2017.

Eylea® (aflibercept Injection) [prescribing information]. Tarrytown, NY. Regeneron Pharmaceuticals, Inc.; 10/2016. Available at: http://hcp.eylea.us/ . Accessed June 2, 2017.

Filho JA, Messias A, Almeida FP, et al. Panretinal photocoagulation (PRP) versus PRP plus intravitreal ranibizumab for high-risk proliferative diabetic retinopathy. Acta Ophthalmol 2011. Epub ahead of print.

Gharbiya M, Giustolisi R, Allievi F, et al. Choroidal neovascularization in pathologic myopia: intravitreal ranibizumab versus bevacizumab--a randomized controlled trial. Am J Ophthalmol. 2010;149(3):458-64.e1.

Heier JS, Brown DM, Chong V, et al; VIEW 1 and VIEW 2 Study Groups. Intravitreal aflibercept (VEGF trap-eye) in wet age-related macular degeneration. Ophthalmology. 2012;119(12):2537-48.

Heier JS, Clark WL, Boyer DS, et al. Intravitreal aflibercept injection for macular edema due to central retinal vein occlusion: two-year results from the COPERNICUS study. Ophthalmology. 2014;121(7):1414-1420.e1.

Jardeleza MS, Miller JW. Review of anti-VEGF therapy in proliferative diabetic retinopathy. Semin Ophthalmol. 2009;24(2):87-92.

Kim M, Lee SC, Lee SJ. Intravitreal ranibizumab for acute central serous chorioretinopathy. Ophthalmologica. 2013;229(3):152-7.

Korobelnik JF, Do DV, Schmidt-Erfurth U, et al. Intravitreal aflibercept for diabetic macular edema. Ophthalmology. 2014;121(11):2247-54. Epub 2014 Jul 8.

Korobelnik JF, Holz FG, Roider J, et al. ; GALILEO Study Group. Intravitreal Aflibercept Injection for Macular Edema Resulting from Central Retinal Vein Occlusion: One-Year Results of the Phase 3 GALILEO Study. Ophthalmology. 2014;121(1):202-8.

Lexi-Drugs Compendium. Aflibercept. 04/15/17. [Lexicomp Online Web site]. Available at: http://online.lexi.com/lco/action/home [via subscription only]. Accessed June 9, 2017.

Lexi-Drugs Compendium. Pegaptanib. 05/01/17. [Lexicomp Online Web site]. Available at: http://online.lexi.com/lco/action/home [via subscription only]. Accessed June 2, 2017.

Lexi-Drugs Compendium. Ranibizumab. 06/01/17. [Lexicomp Online Web site]. Available at: http://online.lexi.com/lco/action/home [via subscription only]. Accessed June 9, 2017.

Loftus JV, Sultan MB, Pleil AM; Macugen 1013 Study Group. Changes in vision- and health-related quality of life in patients with diabetic macular edema treated with pegaptanib sodium or sham. Invest Ophthalmol Vis Sci. 2011;52(10):7498-505.

Lucentis® (ranibizumab injection) [prescribing information]. South San Francisco, CA: Genentech, Inc.; 04/2017. Available at: http://www.lucentis.com/. Accessed June 2, 2017.

Macugen® (Pegaptanib sodium) [prescribing information]. San Dimas, CA. eyetech, Inc.; 07/2016. Available at: http://www.macugen.com/hcp.aspx. Accessed June 2, 2017.

Martin DF, Maguire MG, Fine SL, et al; Comparison of Age-related Macular Degeneration Treatments Trials (CATT) Research Group. Ranibizumab and bevacizumab for treatment of neovascular age-related macular degeneration: two-year results. Ophthalmology. 2012;119(7):1388-98.

Mitchell P, Bandello F, Schmidt-Erfurth U, et al; RESTORE study: Ranibizumab monotherapy or combined with laser versus laser monotherapy for diabetic macular edema. Ophthalmology. 2011;118:615-625.

Novitas Solutions, Inc. Local Coverage Article for Billing and Coding Information Regarding Uses, Including Off-Label Uses, of Anti-Vascular Endothelial Growth Factor (anti-VEGF), for The Treatment of Ophthalmological Diseases (A53121). [Novitas-Solutions Web site]. Original: 10/01/2015. (Revised: 07/11/2016). Available at: https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=53121&ver=7&Date=07%2f11%2f2016&DocID=A53121&bc=hAAAAAgAAAAAAA%3d%3d& . Accessed June 2, 2017.

Pacella E, La Torre G, Impallara D, et al. Efficacy and safety of the intravitreal treatment of diabetic macular edema with pegaptanib: a 12-month follow-up. Clin Ter. 2013;164(2):e121-6.

Rofagha S, Bhisitkul RB, Boyer DS, Sadda SR, Zhang K; SEVEN-UP Study Group. Seven-Year Outcomes in Ranibizumab-Treated Patients in ANCHOR, MARINA, and HORIZON: A Multicenter Cohort Study (SEVEN-UP). Ophthalmology. 2013 May 3. [Epub ahead of print]

Rouvas A, Petrou P, Douvali M, et al. Intravitreal ranibizumab for the treatment of inflammatory choroidal neovascularization. Retina. 2011;31(5):871-9.

Shah M, Amoaku WM. Intravitreal ranibizumab for the treatment of choroidal neovascularisation secondary to angioid streaks. Eye (Lond). 2012;26(9):1194-8.

Sultan MB, Zhou D, Loftus J, Dombi T, Ice KS; Macugen 1013 Study Group. A phase 2/3, multicenter, randomized, double-masked, 2-year trial of pegaptanib sodium for the treatment of diabetic macular edema. Ophthalmology. 2011;118(6):1107-18.

Troutbeck R, Bunting R, van Heerdon A, et al. Ranibizumab therapy for choroidal neovascularization secondary to non-age-related macular degeneration causes. Clin Experiment Ophthalmol. 2012;40(1):67-72.

Truven Health Analytics, Inc. Micromedex® DrugDex® Compendium [Internet database]. Aflibercept. Greenwood Village, CO: Thomson Micromedex. [Micromedex Web site]. 03/02/17. Available at: http://www.micromedexsolutions.com/micromedex2/librarian [via subscription only]. Accessed June 9, 2017.

Truven Health Analytics, Inc. Micromedex® DrugDex® Compendium [Internet database]. Pegaptanib. Greenwood Village, CO: Thomson Micromedex. [Micromedex Web site]. 08/12/16. Available at: http://www.micromedexsolutions.com/micromedex2/librarian [via subscription only]. Accessed June 9, 2017.

Truven Health Analytics, Inc. Micromedex® DrugDex® Compendium [Internet database]. Ranibizumab. Greenwood Village, CO: Thomson Micromedex. [Micromedex Web site]. 04/18/17. Available at: http://www.micromedexsolutions.com/micromedex2/librarian [via subscription only]. Accessed June 9, 2017.

US Food and Drug Administration (FDA). Center for Drug Evaluation and Research. Drugs@FDA. Drug details: Ranibizumab (Lucentis®). [FDA Web site]. 04/2017. Available at: https://www.accessdata.fda.gov/scripts/cder/daf/. Accessed June 2, 2017.

US Food and Drug Administration (FDA). Center for Drug Evaluation and Research. Drugs@FDA. Drug details: Pegaptanib sodium (Macugen®). [FDA Web site]. 01/26/17. Available at: https://www.accessdata.fda.gov/scripts/cder/daf/. Accessed June 2, 2017.

US Food and Drug Administration (FDA). Center for Drug Evaluation and Research. Drugs@ FDA. Drug details: Aflibercept (Eylea®). [FDA Web site]. 05/26/2017. Available at: https://www.accessdata.fda.gov/scripts/cder/daf/. Accessed June 2, 2017.

Virgili G, Parravano M, Menchini F, Brunetti M. Antiangiogenic therapy with anti-vascular endothelial growth factor modalities for diabetic macular oedema. Cochrane Database Syst Rev. 2012;12:CD007419.

Wells JA, Glassman AR, Ayala AR, et al.; Diabetic Retinopathy Clinical Research Network. Aflibercept, Bevacizumab, or Ranibizumab for Diabetic Macular Edema: Two-Year Results from a Comparative Effectiveness Randomized Clinical Trial. Ophthalmology. 2016;123(6):1351-9.

Wolf S, Balciuniene VJ, Laganovska G, et al; RADIANCE Study Group. RADIANCE: a randomized controlled study of ranibizumab in patients with choroidal neovascularization secondary to pathologic myopia. Ophthalmology. 2014;121(3):682-92.e2. Epub 2013 Dec 8.





Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

See Attachment A


HCPCS Level II Code Number(s)

J0178 Injection, aflibercept, 1 mg

J2503 Injection, pegaptanib sodium, 0.3 mg

J2778 Injection, ranibizumab, 0.1 mg



Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References

Attachment A: Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists (e.g., ranibizumab [Lucentis®], pegaptanib sodium [Macugen®], aflibercept [Eylea®], and related biosimilars)
Description: ICD-10 Codes and Narratives




Policy History

Effective 10/05/2017 this policy has been updated to the new policy template
format.
Version Effective Date: 10/30/2017
Version Issued Date: 10/30/2017
Version Reissued Date: N/A

Connect with Us        


© 2017 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.