H35.169 — Retinopathy of prematurity, stage 5, unspecified eye
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Statement of Medical Necessity (SMN) precertification forms: see Specialty Pharmacy Precertification (as referenced).
- For radiation maculopathy/retinopathy: documentation of prior ocular radiation (e.g., proton RT/plaque radiotherapy), clinical signs (macular lipid deposits, hemorrhages, microaneurysms, cystoid edema, telangiectasia, capillary nonperfusion), baseline OCT/FA/OCT-A and follow-up imaging at protocol-specified intervals (eg, baseline, 6, 12, 18 months in referenced study).
- General procedural documentation/consent: documentation that intravitreal injection contraindications are absent (no ocular/periocular infection, no active intraocular inflammation, no known hypersensitivity), and informed consent including injection risks (endophthalmitis, retinal detachment, IOP rise, systemic thromboembolic risk).
Key Coverage Criteria
- Macular edema following cataract surgery (refractory pseudophakic CME)
- Chronic central serous chorioretinopathy (CSC) with intra‑ or sub‑retinal fluid
- Cimerli (ranibizumab-eqrn) — Choroidal retinal neovascularization (FDA)
- Neovascular (wet/exudative) age-related macular degeneration (AMD)
- Byooviz (ranibizumab-nuna) — Age-related macular degeneration (wet/exudative) (FDA)
- Corneal neovascularization (CoNV) and topical/subconjunctival anti-VEGF use — multiple small trials/series (mostly bevacizumab) reported reductions in CoNV; ranibizumab studied in animal and small human reports.
1 Active Policy
AETNA-CPB-0701 — Vascular Endothelial Growth Factor Inhibitors for Ocular Indications
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