Medical Policies - Other


Intravitreal Angiogenesis Inhibitors for Choroidal Vascular Conditions

Number:OTH903.020

Effective Date:10-15-2017

Coverage:

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Medical policies are a set of written guidelines that support current standards of practice. They are based on current peer-reviewed scientific literature. A requested therapy must be proven effective for the relevant diagnosis or procedure. For drug therapy, the proposed dose, frequency and duration of therapy must be consistent with recommendations in at least one authoritative source. This medical policy is supported by FDA-approved labeling and nationally recognized authoritative references. These references include, but are not limited to: MCG care guidelines, Hayes, DrugDex (IIb level of evidence or higher), NCCN Guidelines (IIb level of evidence or higher), NCCN Compendia (IIb level of evidence or higher), professional society guidelines, and CMS coverage policy.

NOTE 1: Information on intravitreal angiogenesis inhibitors (anti-vascular endothelial growth factor [VEGF or anti-VEGF] for retinal vascular disorders can be found on OTH903.027.

Intravitreal injection of anti-VEGF therapies, i.e., pegaptanib (Macugen®), ranibizumab (Lucentis™), bevacizumab (Avastin™), or aflibercept (EYLEA™), may be considered medically necessary for the treatment of neovascular (wet) age-related macular degeneration (AMD).

Intravitreal injection of anti-VEGF therapies may be considered medically necessary for the treatment of choroidal neovascularization (CNV; includes myopic CNV or mCNV) due to:

Angioid streaks,

Central serous chorioretinopathy,

Choroidal retinal neovascularization, secondary to pathologic myopia,

Choroidal retinal neovascularization, degenerative progressive high myopia,

Choroidal rupture or trauma,

Idiopathic choroidal neovascularization,

Multifocal choroiditis,

Pathologic myopia,

Presumed ocular histoplasmosis syndrome, and

Uveitis.

Intravitreal injections of anti-VEGF therapies are considered experimental, investigational and/or unproven for all other choroidal vascular conditions, including but not limited to the treatment of chorioretinal scars.

NOTE 2: For coverage information on verteporfin (Visudyne™), refer to policy OTH903.015, Photodynamic Therapy for Choroidal Neovascularization.

Description:

Angiogenesis inhibitors (e.g., ranibizumab, bevacizumab, pegaptanib, aflibercept) are being evaluated for the treatment of disorders of choroidal circulation. Ophthalmic disorders affecting the choroidal circulation include age-related macular degeneration (AMD), central serous chorioretinopathy (CSC), pathologic myopia, presumed ocular histoplasmosis syndrome, angioid streaks, idiopathic choroidal neovascularization (CNV), uveitis, choroidal rupture or trauma, and chorioretinal scars.

Background

Vascular endothelial growth factor (VEGF) has been implicated in the pathogenesis of a variety of ocular vascular conditions characterized by CNV and macular edema. The macula, with the fovea at its center, has the highest photoreceptor concentration and is where visual detail is discerned. VEGF has been implicated in the pathogenesis of a variety of ocular vascular conditions characterized by neovascularization (including CNV) and macular edema. The anti-VEGF agents ranibizumab (Lucentis™), bevacizumab (Avastin®), pegaptanib (Macugen®), aflibercept (EYLEA™), and Verteporfin (Visudyne™) are used to treat CNV associated with age-related macular degeneration (AMD). The anti-VEGF agents are also being evaluated for the treatment of disorders of retinal circulation (e.g., diabetic retinopathy, retinal vein occlusion, and retinopathy of prematurity). Other therapeutic options may include photodynamic therapy (PDT), antioxidants, and thermal laser photocoagulation. The safety and efficacy of each treatment depends on the form and location of the neovascularization. Angiostatic agents block some stage in the pathway leading to new blood vessel formation (angiogenesis). In contrast to palliative treatments for CNV (e.g., thermal photocoagulation and PDT), they are potentially disease modifying by inhibiting the development of newly formed vessels.

For the treatment of ocular disorders, these agents are given by intravitreal injection every 1 to 2 months. The distinct pharmacologic properties of available VEGF inhibitors suggest that safety and efficacy data from one agent cannot be extrapolated to another. These agents may vary by penetration, potency, half-life, localization to the retina, and initiation of the immune system. Pegaptanib is an oligonucleotide aptamer that binds to the VEGF-165 isomer of VEGF-A. Ranibizumab is an antibody fragment that does not possess the fragment crystallizable domain and is directed at all isoforms of VEGF-A receptors. Bevacizumab is a full-length anti-VEGF antibody derived from the same murine monoclonal antibody precursor as ranibizumab and inhibits all isoforms of VEGF-A. VEGF Trap-Eye (Eylea) is a recombinant fusion protein consisting of the VEGF-binding domains of human VEGF receptors 1 and 2 fused to the Fc domain of human immunoglobulin-G1.

Age-Related Macular Degeneration (AMD or ARMD)

Neovascular AMD is characterized by CNV, which is the growth of abnormal choroidal blood vessels beneath the macula, which causes severe loss of vision and is responsible for most of the loss of vision caused by AMD. In its earliest stages, AMD is characterized by minimal visual impairment and the presence of large drusen and other pigmentary abnormalities on ophthalmoscopic examination. As AMD progresses, 2 distinctively different forms of degeneration may be observed. The first, called the atrophic or areolar or dry form, evolves slowly. Atrophic AMD is the most common form of degeneration and is often a precursor of the second form, the more devastating exudative neovascular form, also referred to as disciform or wet degeneration. The wet form is distinguished from the atrophic form by serous or hemorrhagic detachment of the retinal pigment epithelium and the development of CNV, sometimes called neovascular membranes. Risk of developing severe irreversible loss of vision is greatly increased by the presence of CNV. The pattern of CNV, as revealed by fluorescein or indocyanine angiography, is further categorized as classic or occult. For example, classic CNV appears as an initial lacy pattern of hyperfluorescence followed by more irregular patterns as the dye leaks into the subretinal space. Occult CNV lacks the characteristic angiographic pattern, either due to the opacity of coexisting subretinal hemorrhage or, especially in CNV associated with AMD, by a tendency for epithelial cells to proliferate and partially or completely surround the new vessels. Interestingly, lesions consisting only of classic CNV carry a worse visual prognosis than those made up of only occult CNV, suggesting that the proliferative response that obscures new vessels may also favorably alter the clinical course of AMD.

Intravitreal triamcinolone acetonide is one of the first pharmacologic compounds evaluated for the treatment of CNV secondary to AMD. The most important effects of this treatment consist of the stabilization of the blood-retinal barrier and the down-regulation of inflammation. Triamcinolone acetonide also has antiangiogenic and anti-fibrotic properties and remains active for months after intravitreal injection. However, cataracts are a common adverse effect, and steroid-related pressure elevation occurs in approximately one third of patients, with some requiring filtration surgery.

Photodynamic therapy (PDT) is a treatment modality designed to selectively occlude ocular choroidal neovascular tissue. The therapy is a 2-step process, consisting initially of an injection of the photosensitizer verteporfin, followed 15 minutes later by laser treatment to the targeted sites of neovascularization in the retina. The laser treatment selectively damages the vascular endothelium. Patients may be retreated if leakage from CNV persists. Combination therapy with PDT and VEGF antagonists is being investigated. Refer to OTH903.015, Photodynamic Therapy for Choroidal Neovascularization, for coverage information.

Before the availability of angiostatic agents and PDT, CNV was treated with photocoagulation using either argon, green, or infrared lasers. This conventional photocoagulation was limited to extrafoveal lesions due to the risk of retinal burns. Introduction of a scotoma or enlargement of a pre-existing scotoma, with or without visual acuity loss, is an immediate and permanent effect of photocoagulation surgery. Because of the loss of vision associated with laser photocoagulation, photocoagulation is no longer recommended as the initial treatment of subfovealeovascularization.

Polypoidal Choroidal Vasculopathy (PCV)

PCV is characterized by the presence of a branching vascular network with terminal, polyp-like aneurismal dilations. Some investigators consider PCV to be a subtype of AMD, while others suggest that the lesions, when submacular, can be mistaken for AMD. PCV is more common in Asian compared with white populations. Both PDT and ranibizumab have been used to treat PCV; although the optimal treatment for PCV may differ from that for AMD.

Central Serous Chorioretinopathy (CSC)

CSC is the fourth most common retinopathy after AMD, diabetic retinopathy, and branch retinal vein occlusion. CSC refers to an idiopathic disease in which there is a serious detachment of the macula due to leakage of fluid from the choriocapillaris through the retinal pigment epithelium. CSC can be divided into acute, recurrent, and chronic conditions. Usually, serous retinal detachments have spontaneous resolution with recovery of visual function; however, a subset of patients may experience permanent deterioration of visual function attributable to chronic CSC or multiple recurrences of CSC. The pathogenesis of CSC is believed to be ischemia and inflammation, which lead to abnormal permeability of the inner choroid and elevation of the retinal pigment epithelium, causing serous epithelial detachments. The separated retinal pigment epithelium can then undergo tiny rips (blowouts) with a break in continuity. The change in permeability of the retinal pigment epithelium results in focal leakage and retinal detachment. Neovascularization can occur as a secondary complication. In about 90% of cases, CSC resolves spontaneously with detachment resolution within 3 months. The traditional management of acute CSC is observation. Recurring or chronic CSC can be treated with focal laser photocoagulation if the leaks are extrafoveal. Although laser may shorten the duration of symptoms, it does not have any impact on the final vision or the recurrence rate of CSC. In addition, laser photocoagulation causes collateral damage creating symptomatic scotomas and a risk of triggering secondary CNV. PDT is not a standard treatment for CSC due to complications that may include CNV, although low-fluence PDT is being evaluated.

Other Causes of CNV

Other causes of CNV include pathologic myopia, presumed ocular histoplasmosis syndrome, angioid streaks, idiopathic CNV, uveitis, choroidal rupture or trauma, and chorioretinal scars. Treatments that have been evaluated for CNV not related to AMD include submacular surgery, laser photocoagulation, and PDT. Efficacy of these treatment modalities is limited.

Regulatory Status

Pegaptanib (Macugen®, Eyetech and Pfizer), ranibizumab (Lucentis™, Genentech) and aflibercept (Eylea™, Regeneron Pharmaceuticals), are approved by the U.S. Food and Drug Administration (FDA) for use in AMD. Pegaptanib was the first VEGF antagonist to be approved by the FDA for use in neovascular (wet) AMD in 2004. Ranibizumab was approved for the treatment of patients with neovascular (wet) AMD in 2006. Pegaptanib and ranibizumab bind extracellular VEGF to inhibit the angiogenesis pathway and are administered by intravitreous injections every 4 to 6 weeks. Pegaptanib binds to the VEGF-165 isomer of VEGF-A, while ranibizumab is an antibody fragment directed at all isoforms of VEGF-A. On January 13, 2017, the FDA approved ranibizumab (Lucentis™) for the treatment of myopic CNV (mCNV).

Aflibercept (EYLEA™, previously called VEGF Trap-Eye) is a recombinant fusion protein consisting of the VEGF binding domains of human VEGF receptors R1 and R2 fused to the Fc domain of human immunoglobulin-G1. Aflibercept was approved by the FDA in 2011 for the treatment of neovascular (wet) AMD. The recommended dose for EYLEA™ is 2 mg (0.05 mL) administered by intravitreal injection every 4 weeks (monthly) for the first 3 months, followed by 2 mg (0.05 mL) via intravitreal injection once every 8 weeks (2 months).

Ranibizumab and aflibercept are also approved by the FDA for retinal vascular conditions such as diabetic macular edema and macular edema following retinal vein occlusion (see Medical Policy, OTH903.027).

Bevacizumab (Avastin®) is derived from the same murine monoclonal antibody precursor as ranibizumab, which binds to all isoforms of VEGF-A. Bevacizumab has been developed and approved for use in oncology but has not been licensed for use in the eye. Therefore, any treatment of the eye with bevacizumab is considered an off-FDA-labeled use of a FDA approved drug.

Rationale:

This policy was originally created in 2003 targeting conditions related to choroidal vascular disorders and periodically updated with literature searches of MedLine. In 2009, conditions related to retinal vascular disorders were added to the policy; however, coverage information on retinal vascular disorders has been moved to OTH903.024 in 2014. The most recent literature search was performed through July 31, 2016. The following is a summary of key literature to date.

Age-related Macular Degeneration (AMD)

A 2014 Cochrane review evaluated antivascular endothelial growth factor (anti-VEGF) therapies pegaptanib, ranibizumab, bevacizumab) for neovascular age-related macular degeneration (AMD). (1) This systematic review included 12 randomized controlled trials (RCTs) with a total of 5496 patients. There were 5 trials of pegaptanib, ranibizumab, or bevacizumab compared with controls and 6 trials that compared bevacizumab with ranibizumab. The number of participants per trial ranged from 28 to 1208. There was a low risk of bias in the included trials, and the overall quality of the evidence was considered to be very good. Patients treated with any of the anti-VEGF treatments were more likely to have gained 15 letters or more of visual acuity, lost fewer than 15 letters of visual acuity, and have vision 20/200 or better compared with controls. Improvements in vision were found to be similar for ranibizumab and bevacizumab, while both of these agents resulted in greater improvements in visual outcomes compared with pegaptanib. Trials with aflibercept were not included in the review. Details of relevant trials are described below.

Pegaptanib (Macugen®):

Pegaptanib was compared with sham in 2 concurrent multicenter double-masked studies by the VEGF Inhibition Study in Ocular Neovascularization (VISION) Clinical Trial Group in 2004. (2) Patients with all angiographic subtypes of lesions were enrolled if they had subfoveal sites of choroidal neovascularization (CNV) secondary to AMD. A total of 1208 patients were randomized to a dose of 0.3, 1.0, or 3.0 mg pegaptanib or sham injections, administered every 6 weeks over a period of 48 weeks. The use of PDT was permitted only in the treatment of patients with predominantly classic lesions by an ophthalmologist who was masked to the treatment assignment. A total of 1186 patients received at least 1 study treatment, had visual acuity assessments at baseline, and were included in efficacy analyses. Approximately 90% of the patients in each treatment group completed the study, and an average of 8.5 injections was administered per patient. In the combined analysis, there was a significant improvement in the primary end point of the proportion of patients who had lost fewer than 15 letters of visual acuity for all 3 doses of pegaptanib. In the sham group, 55% of patients lost fewer than 15 letters at 54 weeks. In the 0.3-, 1.0-, and 3.0-mg groups, the percentage of patients who lost fewer than 15 letters was 70%, 71%, and 65%, respectively. The risk of severe loss of visual acuity (≥30 letters) was reduced from 22% in the sham injection group to 8% to 14% in the pegaptanib groups. More patients receiving pegaptanib maintained their visual acuity or gained acuity (31%-37% versus 23%, respectively). Use of PDT after baseline was similar in the 4 groups, ranging from 17% to 21% of patients. Adverse events (AEs) associated with a severe loss of visual acuity occurred in 0.1% of patients. Discontinuation of therapy due to AEs was 1% in the pegaptanib and sham groups. No RCTs with pegaptanib were identified after 2004.

Ranibizumab (Lucentis™):

The ANCHOR Study:

Ranibizumab was compared with photodynamic therapy (PDT) in a multicenter, manufacturer-funded double-blind study (423 patients) designated Anti-VEGF Antibody for the Treatment of Predominantly Classic Choroidal Neovascularization in Age-Related Macular Degeneration (ANCHOR) in 2006. (3) Patients with subfoveal CNV and a predominantly classic lesion (n=423) were randomized in a 1:1:1 ratio to receive 0.3 mg (n=137) or 0.5 mg (n=139) of intravitreal ranibizumab plus sham verteporfin or sham injections plus active verteporfin (n=142) monthly. Patients were to receive monthly injections for 2 years in the study eye. Only 1 eye per patient was chosen as the study eye, and only the study eye received ranibizumab with sham PDT or sham injection with active PDT. The primary, intention-to-treat efficacy analysis was at 12 months, with continued measurements to month 24. Key measures included the following: the percentage losing fewer than 15 letters from baseline visual acuity score (month 12 primary efficacy outcome measure); percentage gaining more than 15 letters from baseline; and mean change over time in visual acuity score and fluorescein angiography-assessed lesion characteristics. AEs were monitored. Following 12 monthly treatments, patient groups treated with ranibizumab (0.3 or 0.5 mg) and sham verteporfin had 94% to 96% of subjects lose fewer than 15 letters. The patient group treated with monthly sham injection and active verteporfin therapy (average, 2.8 times over the year) had 64% of subjects lose fewer than 15 letters. Visual acuity improved by more than 15 letters in 36% and 40% of the ranibizumab groups (average dose-dependent gain, 8.5 and 11.3 letters), in comparison with 5.6% of subjects in the verteporfin group (average loss, 9.5 letters). Intraocular inflammation occurred in 10.2% and 15% of ranibizumab-treated patients, with presumed endophthalmitis in 1.4% and serious uveitis in 0.7% of patients treated with the highest dose.

Brown et al. reported the 2-year results of the trial by the ANCHOR study group in 2009. (4) Of 423 patients, at least 77% in each group completed the 2-year study. Consistent with results at month 12, at month 24, the visual acuity benefit from ranibizumab was statistically significant and felt to be clinically meaningful; 89.9% to 90.0% of ranibizumab-treated patients had lost fewer than 15 letters from baseline versus 65.7% of PDT patients; and 34% to 41.0% had gained 15 or more letters versus 6.3% of the PDT group. Changes in lesion anatomic characteristics on fluorescein angiography also favored ranibizumab. There was a trend for an increased incidence of cataract in the ranibizumab groups compared with the PDT group, which was statistically significant at the 0.5-mg dose. There were no statistically significant differences among the 3 treatment groups in the rates of serious nonocular AEs. In this 2-year study, ranibizumab provided greater clinical benefit than verteporfin PDT in patients with AMD with new-onset, predominantly classic CNV.

Bressler et al. reported a subanalysis of the patient-reported outcomes from the ANCHOR trial. (5) The National Eye Institute Visual Functioning Questionnaire?25 (VFQ-25) was administered at baseline and at 1, 2, 3, 6, 9, 12, 18, and 24 months. The primary outcome measure was mean change from baseline in VFQ-25 scores at 12 months. At 12 months, patients treated with ranibizumab had mean improvements in VFQ-25 composite scores of 5.9 (range, 3.6-8.3) for 0.3-mg dose group and 8.1 (range, 5.3-10.8) points for the 0.5-mg dose group; patients treated with PDT had a mean improvement of 2.2 points (range, -0.3 to 4.7). At each dose through 24 months, patients treated with ranibizumab were more likely to improve in most subscales, including the prespecified subscales (near vision activities, distance vision activities, vision-specific dependency).

The HORIZON Study:

In 2012, Singer et al. reported a 2-year open-label extension trial of ranibizumab for CNV secondary to AMD in patients who had completed 1 of 3 randomized 2-year clinical trials (ANCHOR, FOCUS, MARINA). (6) There were 600 patients treated with ranibizumab in the initial studies, 190 patients who were initially in the control arm and crossed over to ranibizumab for the extension study, and 63 patients who remained ranibizumab-naive. Ranibizumab was administered at the investigator’s discretion (no prespecified retreatment criteria). Follow-up was scheduled quarterly for 24 to 40 months, although investigators could see patients more frequently. On average, patients were seen about every 2 months, and the average number of injections was 2.1 for year 1, 4.4 for year 2, and 4.7 for year 3. The primary outcome, ocular safety, did not identify any serious AEs with intravitreal ranibizumab. While retinal hemorrhage was increased, cataracts were decreased. There was also a decline in visual acuity in the open-label phase with the less frequent treatment. At 24 months from the baseline of the open-label phase, best-corrected visual acuity (BCVA) decreased from +9.0 to +2.0 in the ranibizumab-treated group and from -9.6 to -11.8 in the 2 control groups.

In 2012, Bressler et al. conducted an exploratory analysis of the rate of cerebrovascular accidents (CVA) with ranibizumab. (7) With data pooled from 5 trials (FOCUS, MARINA, ANCHOR, PIER, SAILOR), CVA rates were less than 3%. The odds ratios for CVA risk were 1.2 for 0.3 mg ranibizumab versus control, 2.2 for 0.5 mg versus control, and 1.5 for 0.5 mg versus 0.3 mg ranibizumab. These results are considered preliminary, but do suggest the need for continued monitoring for CVA with anti-VEGF agents.

Bevacizumab (Avastin®):

The ABC Trial:

In 2010, Tufail et al. reported a randomized multicenter study (ABC Trial) of bevacizumab for neovascular AMD in 131 patients (eyes), 65 of whom received bevacizumab. (8) Outcomes at 54 weeks were compared with patients who had received standard care from the U.K.’s National Health Service (NHS), which was considered on a case-by-case basis. Patients with classic or predominantly classic CNV were randomized to PDT or bevacizumab with sham PDT. Patients with minimally classic or occult CNV were randomized to bevacizumab or (depending on NHS funding) pegaptanib or placebo. The standard care group included 38 patients treated with pegaptanib, 16 treated with verteporfin, and 12 treated with a sham intravitreal injection. Bevacizumab (1.25 mg in 0.05 mL) was prepared in single-use sterile plastic syringes in sealed plastic pouches (shelf life of 6 weeks) and administered once every 6 weeks for the first 18 weeks; further injections were provided based on standardized criteria. Patients received a mean of 7.1 (range, 3-9) injections of bevacizumab or 7.3 (range, 3-9) sham injections. Active verteporfin PDT was administered at a mean of 3.2 times (range, 2-5). Independent assessment of outcomes found that 21 patients (32%) in the bevacizumab group gained 15 or more letters compared with 2 (3%) in the standard care group. More patients receiving bevacizumab lost fewer than 15 letters (91% versus 67%, respectively). The mean change in visual acuity at 54 weeks increased by +7.0 letters in the bevacizumab group and decreased by -9.4 letters in the standard care group.

Aflibercept (EYLEA™):

The VIEW 1 and VIEW 2 Trials:

Data submitted to the U.S. Food and Drug Administration (FDA) and published in 2012 included 52-week results from 2 multicenter double-masked, randomized trials (VIEW1 and VIEW2) that compared 3 doses of aflibercept (VEGF Trap-Eye) with ranibizumab (0.5 mg). (9, 10) A total of 2457 patients with all 3 subtypes of AMD (occult, minimally classic, predominantly classic) were enrolled in the 2 studies. VIEW1 was conducted primarily in North America and VIEW2 was conducted primarily in Europe, Asia, Australia, and Latin America. Both trials used a non-inferiority design with a 10% margin and tested doses of aflibercept at 0.5 mg every 4 weeks, 2.0 mg every 4 weeks, and 2.0 mg every 8 weeks after 3 initial monthly doses. Ranibizumab (0.5 mg) was administered every 4 weeks. Between 52 and 96 weeks, patients received the assigned study drug as needed (PRN) based on standardized criteria. (11) All doses of aflibercept met non-inferiority compared with 0.5 mg ranibizumab, with about 94% of patients maintaining vision (losing <15 letters) at week 52. At week 96, about 92% of patients in all groups had maintained stable vision. Post hoc analysis found that the number of injections in the 2-mg aflibercept groups (4.1 and 4.2) was statistically lower than in the ranibizumab group (4.7).

In addition to VIEW1 and VIEW2, safety and tolerability of aflibercept was evaluated in a 3-year extension study with 157 patients. Intravitreal injections of aflibercept were given as needed, not more frequently than every 4 weeks. The most common adverse reactions (≥5%) reported in patients receiving aflibercept injection were conjunctival hemorrhage, eye pain, cataract, vitreous detachment, vitreous floaters, and increased intraocular pressure (IOP). The data provided from these 3 trials were found to support the safety of aflibercept injection in the treatment of patients with neovascular (wet) AMD. The dose of 2 mg every 8 weeks was recommended for the labeling of aflibercept, because it has fewer injections than the other two doses studied and has the theoretical benefit of less injection-related risks (i.e., endophthalmitis).

Section Summary: Age-related Macular Degeneration:

There is RCT evidence supporting the efficacy of all 4 agents (bevacizumab, ranibizumab, pegaptanib, aflibercept) for preserving visual acuity in patients with AMD. These trials report that VEGF inhibitors are superior to placebo and superior to PDT. A preliminary report of increased stroke rates in patients treated with ranibizumab was published in 2012.

On-Label Versus Off-Label Use of VEGF inhibitors

The CATT Study:

There has been considerable interest in determining whether efficacy of bevacizumab used off-label is similar to ranibizumab, which is specifically approved for use in the eye. In 2011, the 1-year results of the National Eye Institute?sponsored multicenter (44 sites) Comparison of AMD Treatment Trials (CATT) were published. (12) CATT was a randomized single-blind head-to-head comparison of the safety and effectiveness of ranibizumab and bevacizumab in treating wet AMD. A total of 1208 patients with previously untreated active CNV due to AMD (neovascularization, fluid, or hemorrhage under the fovea) and visual acuity between 20/25 and 20/320 were enrolled in the study. Patients were randomly assigned to receive intravitreal injections of ranibizumab (0.5 mg) or bevacizumab (1.25 mg) on either a monthly schedule or as needed with monthly evaluation. The mean number of injections on the as needed schedule was 6.9 for ranibizumab and 7.7 for bevacizumab over the first year of the study (significantly different). The primary outcome measure was a change in visual acuity at 1 year, with a non-inferiority limit of 5 letters on the eye chart.

When administered according to the same schedule, bevacizumab and ranibizumab had equivalent (not inferior) effects on visual acuity. With bevacizumab and ranibizumab administered monthly, patients gained an average of 8.0 and 8.5 letters, respectively. When administered as needed, the number of letters gained with bevacizumab was similar to that of ranibizumab, with 5.9 and 6.8 letters gained, respectively. At 1 year, there were no significant differences in the proportion of patients who lost or gained 15 or more letters. There were significant differences in the anatomy of the retina with the different treatments. At 1 year, monthly ranibizumab decreased central retinal thickness to a greater extent (196 microns) than the other 3 groups (152 to 168 microns). The absolute between-drug difference in the amount of residual fluid was small; at 1 year, total thickness at the fovea was 266 microns for the ranibizumab monthly group and close to 300 microns for the other 3 groups. In comparison, the retinal thickness of healthy eyes measured by optical coherence tomography (OCT) at the fovea averages 212 microns. (13) Rates of death, myocardial infarction (MI), and stroke were similar for patients receiving either bevacizumab or ranibizumab. The proportion of patients with serious systemic AEs (primarily hospitalizations) was higher with bevacizumab than with ranibizumab, although these events were broadly distributed in disease categories not considered to be areas of concern for use of bevacizumab and were not dose-dependent.

An accompanying editorial noted that although the OCT retinal thickness measurements favor ranibizumab, this difference was not reflected in any of the visual-acuity or angiographic outcomes; whether this difference was associated with changes in vision would become clearer during the second year of follow-up. (14) In 2012, the CATT Research Group reported the 2-year follow-up on 1107 of the 1185 patients enrolled in the trial. (15) Visual acuity gains at 2 years were similar to those obtained at 1 year, ranging from 5.0 to 8.8 letters, and when following the same treatment regimen, the mean gain in visual acuity was similar for ranibizumab and bevacizumab. The proportion of patients with 1 or more systemic serious AEs was higher with bevacizumab (39.9% versus 31.7%), although most of the excess events were not previously associated with systemic VEGF inhibitors.

Several research groups from Europe also found no evidence of inferiority in visual outcomes with off-label use of bevacizumab. The IVAN study was a multicenter double-masked non-inferiority trial from the United Kingdom that randomized 610 patients to ranibizumab or bevacizumab given monthly, or ranibizumab or bevacizumab given PRN. (16) Results at 1 and 2 years were inconclusive (bevacizumab was neither inferior nor equivalent with a mean difference of -1.37 letters). (17) The GEFAL study was a randomized double-masked non-inferiority trial from France with 501 patients. (18) In both per protocol and intention-to-treat analysis, bevacizumab was non-inferior to ranibizumab (mean difference, +1.89 letters). The multicenter MANTA research group from Austria reported a double-masked randomized non-inferiority trial comparing ranibizumab and bevacizumab in 317 patients with AMD. (19) At 12 months, there was a similar increase in visual acuity for the 2 groups (4.9 letters in the bevacizumab group, 4.1 letters in the ranibizumab group).

The potential for an increased risk of AEs with bevacizumab remains controversial. A randomized study from 2013 found that a single intravitreal injection of bevacizumab led to significantly reduced levels of VEGF in plasma (from 89.7 pg/mL to 22.8 pg/mL) for up to 1 month after intravitreal injection. (20) However, this large reduction appears to be driven largely by 1 outlier with plasma VEGF levels of close to 400 pg/mL. VEGF levels in plasma were not affected by ranibizumab or pegaptanib. In 2012, Schmucker et al. reported a meta-analysis of the safety of bevacizumab compared with ranibizumab. (21) Direct comparison (3 trials, 1333 patients) found a significantly higher rate of ocular and systemic AEs with bevacizumab compared with ranibizumab. Arterial thromboembolic events were similar between the 2 conditions.

A retrospective analysis of claims from 146,942 Medicare beneficiaries compared treatment with PDT, pegaptanib, bevacizumab, or ranibizumab. (22) After adjustment for baseline characteristics and comorbid conditions, there were no significant differences in the hazard of mortality or MI between bevacizumab use and the other therapies. There was no statistically significant relationship between treatment group and bleeding events or stroke. In contrast, a 2011 preliminary report of 77,886 Medicare beneficiaries found an 11% higher risk in overall mortality and a 57% higher risk of hemorrhagic CVA following treatment with bevacizumab in comparison with ranibizumab. (23) The authors note that the study is limited by incomplete information on some important confounding factors, e.g., smoking, lipid and blood pressure levels, which would further clarify the relative safety of these treatments in wet AMD.

Section Summary: On-Label Versus Off-Label Use of VEGF inhibitors:

Evidence on comparative effectiveness indicates there are no substantial differences in efficacy between bevacizumab and ranibizumab for the treatment of AMD. The evidence on AEs is not conclusive on whether bevacizumab is associated with a higher rate of AEs compared with ranibizumab.

Other Causes of CNV

The literature on angiogenesis inhibitors for the treatment of other causes of CNV consists of cases series and small controlled trials. Following is a summary of the key literature to date, focusing on controlled trials.

A 2011 U.S. multicenter phase 1 trial examined the efficacy of ranibizumab for CNV secondary to causes other than AMD. (24) Thirty patients with pathologic myopia (n=14), ocular histoplasmosis (n=9), angioid streaks (n=3), idiopathic telangiectasia (n=1), idiopathic chorioretinal scar (n=1), choroidal ruptures (n=1), or central serous retinopathy (n=1) were randomly assigned to monthly intravitreal injections of 0.5 mg ranibizumab or 3 monthly injections followed by as needed (PRN) at monthly follow-up visits. In the PRN group, retreatment was performed at follow-up visits if the study eye met prespecified criteria. A mean of 5.93 injections (range, 3-11) were administered to evaluable patients (n=14) in the PRN treatment arm compared with 11.17 injections among evaluable patients (n=12) in the monthly treatment arm. The mean BCVA at baseline was 53.5 and 48 letters in the monthly and PRN treatment arms, respectively. At 12 months (87% follow-up), mean visual acuity had improved by 26.9 and 19.2 letters in the 2 groups, respectively. Eight of 12 (66.7%) patients who received monthly injections gained 15 or more letters, compared with 8 of 14 (57.1%) on the PRN schedule. No patient in the study lost 15 or more letters. The mean baseline central retinal thickness was 345 microns and 383 microns in patients in the monthly and PRN treatment arms, respectively. Central retinal thickness decreased by 109.3 microns in the monthly group and 166.6 microns in the PRN treatment group. No statistically significant differences were observed between treatment groups. The most common ocular AEs included 5 cases of subconjunctival hemorrhage, 4 cases of ocular pain or soreness, 2 cases of vitreous floaters, 1 case of retinal hemorrhage, and 2 cases of transiently elevated IOP. The study concluded that intravitreal ranibizumab has a promising safety and efficacy profile in the treatment of CNV unrelated to AMD and that larger, randomized studies are warranted to confirm these findings and to determine the optimal dosing regimen for ranibizumab.

Chen et al. assessed visual outcomes and retreatment rates in a retrospective comparison of bevacizumab alone or bevacizumab combined with PDT. (25) Included were 23 patients with subfoveal CNV due to causes other than AMD (myopia, presumed ocular histoplasmosis, angioid streaks, choroiditis, idiopathic, central serous chorioretinopathy). At 12-month follow-up, the mean change in visual acuity was a gain of 1.7 lines in the monotherapy group (n=17) compared with 2.8 lines in the combination therapy group (n=6; p=0.45). At 12 months, 36% in the bevacizumab monotherapy group gained more than 3 lines of vision compared with 60% in the combination group (p=0.60). The monotherapy group received a mean of 4.8 reinjections, while the combination group received 2.6 injections over 12 months (p=0.11).

Angioid Streaks:

A 2013 meta-analysis identified 54 small series (≥3 cases) on the treatment of angioid streaks; no RCTs were identified. (26) While PDT (11 studies) was found to slow down disease progression, VEGF inhibitors (16 studies) stabilized or improved vision. Pooled analysis showed superior results for VEGF inhibitors, with a mean difference between the treatments of approximately 6 lines.

Central Serous Chorioretinopathy:

In 2014, Bae et al. reported 1-year results from a small randomized trial that compared low-fluence PDT versus ranibizumab in 34 eyes (32 patients) with chronic (≥6 months) or recurrent central serous chorioretinopathy. (27) Rescue with the other treatment was available after 3 months if subretinal fluid persisted or recurred. Masked evaluation at 1 year found complete resolution of subretinal fluid without rescue treatment in 16 eyes (88.9%) of the PDT group compared with 2 eyes (12.5%) in the ranibizumab group. The improvement in BCVA at 3 months was significantly greater in the PDT group compared with the ranibizumab-treated eyes (.25 versus .12 logMAR). At 1 year (after rescue treatment), there was no significant difference in BCVA between the 2 groups.

Literature searches also identified 2 small controlled studies from Asia that assessed the efficacy of bevacizumab for central serous chorioretinopathy (CSC) compared with no treatment. In a 2010 report, 32 eyes with acute CSC (<3 months in duration) were randomized to a single intravitreal injection of bevacizumab or to observation. (28) During the 6-month follow-up, there were no significant differences in visual acuity, central retinal thickness, or remission duration between the bevacizumab and control group. All patients had complete resolution of their macular subretinal fluid during the 6-month follow-up. In another prospective study, 15 eyes of 15 patients with persistent CSC (>3 months) treated with a single intravitreal injection of bevacizumab were compared with 15 eyes with the same characteristics from patients who declined treatment. (29) At 6-month follow-up, the mean logMAR BCVA was significantly better in the treatment group (0.03) compared with the control group (0.14), and all 15 (100%) treated eyes had stable or improved vision, compared with 10 (66%) eyes in the control group.

Multifocal Choroiditis:

In 2010, Parodi et al. reported a pilot RCT that compared intravitreal bevacizumab and PDT in 27 patients with CNV associated with multifocal choroiditis. (30) Retreatments (2.8 for bevacizumab, 0.7 for PDT) were performed if any leakage from CNV was noted on fluorescein angiography. At the 12-month follow-up, 5 of 14 eyes (36%) in the bevacizumab group and 0 of 13 eyes (0%) in the PDT group had a gain of 3 or more lines of vision. Twelve eyes (86%) in the bevacizumab group and 6 eyes (46%) in the PDT group gained more than 1 line. There was a significant difference in BCVA favoring the bevacizumab group at the end of follow-up. The 2 groups showed a similar improvement in central macular thickness.

Pathologic Myopia:

RADIANCE Study:

RADIANCE was a 12-month, phase 3, multicenter, double-masked randomized trial that compared ranibizumab with PDT in 277 patients with myopic CNV. (31) Treatment with ranibizumab continued on a monthly basis until BCVA stabilized (group I) or there was no disease activity (group II). Patients in the PDT group (group III) could be treated with ranibizumab from months 3 to 11 if disease activity was observed. All patients were treated with sham injection or PDT sham together with the study treatment to maintain masking, and evaluations were performed by an investigator not involved in the treatment. Patients who were initially treated with ranibizumab followed by PRN ranibizumab had superior visual acuity outcomes compared with PDT from month 1 through month 3. Group I gained 10.5 letters, group II gained 10.6 letters, compared with a gain of 2.2 letters following treatment with PDT (p<0.000). Groups I and II continued to improve in BCVA up to month 12. Ranibizumab was allowed after month 3 in group III, at which time BCVA steadily improved.

In 2017, the FDA based their approval of ranibizumab (Lucentis™) for the treatment of myopic CNV on one unpublished study described below. (47)

The efficacy and safety data of Lucentis™ were assessed in a randomized, double-masked, active-controlled 3-month study in patients with mCNV. Patients age ranged from 18 to 87 years, with a mean age of 55 years. A total of 276 patients (222 patients in the Lucentis™ treated Groups I and II; 55 patients in the active control verteporfin photodynamic therapy (vPDT) group) were enrolled. Patients randomized to the Lucentis™ groups received injections guided by pre-specified re-treatment criteria. The retreatment criteria in Group I were vision stability guided, with the BCVA at the current visit being assessed for changes compared with the two preceding monthly BCVA values. The retreatment criteria in Group II were disease activity guided, based on BCVA decrease from the previous visit that was attributable to intra-or sub-retinal fluid or active leakage secondary to mCNV as assessed by OCT and/or fluorescein angiography (FA) compared to the previous monthly visit.

Visual gains for the two Lucentis™ 0.5 mg treatment arms were superior to the active control arm. The mean change in BCVA from baseline at month 3 was: +12.1 letters for Group I, +12.5 letters for Group II and +1.4 letters for the vPDT group. Table 1 compares the efficacy between Group I and Group II.

Table 1. Mean Change in Visual Acuity and Proportion of Patients Who Gained ≥15 Letters from Baseline at Month 3

Study Arms

Mean Change in BCVA from Baseline (Letters)

Proportion of Patients Who Gained ≥15 Letters from Baseline

Mean (SD)

Estimated Difference (95% CI) a

Percent

Estimated Difference (95% CI) a

Group I

12.1 (10.2)

10.9

(7.6, 14.3)

37.1

22.6

(9.5, 35.7)

Group II

12.5 (8.8)

11.4

(8.3, 14.5)

40.5

26.0

(13.1, 38.9)

Control (vPDT)

1.4 (12.2)

14.5

Table Key:

BCVA: best-corrected visual acuity;

SD: mean;

CI: confidence interval;

a: Adjusted estimates based on stratified models, p<0.01

vPDT: verteporfin photodynamic therapy.

The proportion of patients who gained ≥15 letters by month 3 was 37.1% and 40.5% for Lucentis™ Groups I and II, respectively and 14.5% for the vPDT group. The mean number of injections between baseline and month 3 was 2.5 and 1.8 for Groups I and II, respectively. 41% of patients received 1, 2 or 3 injections between baseline and month 3 with no injections afterwards.

Parodi et al. compared intravitreal bevacizumab with laser photocoagulation and PDT in a randomized trial of 54 patients with juxtafoveal CNV secondary to pathologic myopia in 2010. (32) Additional intravitreal bevacizumab injections were administered when OCT revealed persistent or recurrent fluid, or when the fluorescein angiography examination revealed CNV activity or progression. Eyes in the laser therapy or PDT groups that developed recurrent CNV with subfoveal location during follow-up could be retreated using PDT. At 24 months, the bevacizumab group had gained 1.8 lines from baseline with a mean of 3.8 intravitreal bevacizumab injections; 4 of 19 eyes (21%) required intravitreal bevacizumab injections during the second year. The laser photocoagulation group lost 1.1 lines with a mean of 1.17 PDT treatments, and the PDT group lost 2 lines with 2.55 retreatments.

A 2012 study from the same group of investigators compared ranibizumab PRN versus bevacizumab PRN in 48 eyes with neovascularization secondary to pathologic myopia. (33) Although this randomized study does not appear to be double-masked, the authors reported that visual acuity was assessed by an examiner who was unaware of the purpose of the study. At 18-month follow-up, there was no significant difference in mean BCVA between the 2 groups (0.42 logMAR for ranibizumab versus 0.53 logMAR for bevacizumab). A 3-line or higher gain was reported for 30% of eyes in the ranibizumab group and 44% of eyes in the bevacizumab group. Stabilization of CNV was observed in 100% of ranibizumab-treated eyes and 84% of bevacizumab-treated eyes. Fewer injections were administered in the ranibizumab group (2.5) compared with the bevacizumab group (4.7).

Another small randomized trial from 2010 compared ranibizumab and bevacizumab in 32 eyes (32 patients) with pathologic myopia. (34) Follow-up was performed at 1, 3, and 6 months. BCVA at baseline was 26.44 letters in the ranibizumab group and 29.50 letters in the bevacizumab group. At 6 months, ranibizumab-treated eyes had gained 17.31 letters and bevacizumab-treated eyes had gained 15.87 letters. Twelve eyes in the ranibizumab group (75%) and 13 in the bevacizumab group (81.2%) gained 10 or more letters. Foveal center thickness improved from 251 to 206 microns with ranibizumab and from 237 to 185 microns with bevacizumab. No significant differences in BCVA improvement or foveal center thickness reduction were found between the groups. Complete resolution of fluorescein leakage was observed in all 16 bevacizumab-treated eyes and in 15 of 16 (93.7%) of ranibizumab-treated eyes.

NCT01249664 is a study with 122 patients with myopic CNV randomized to aflibercept or sham injection. Results have been posted, but no published results have been identified as of February 19, 2015.

The off-FDA-label indication for treatment of choroidal retinal neovascularization, secondary to pathologic myopia is supported by the DrugDex Compendia using ranibizumab. (42) Additionally, DrugDex Compendia supported the FDA off-labeled indication of choroidal retinal neovascularization, degenerative progressive high myopia using bevacizumab. (43) There were no FDA off-labeled CNV-related indications for pegaptanib or aflibercept within the DrugDex Compendia. (44, 45)

Polypoidal Choroidal Vasculopathy:

The LAPTOP Study:

LAPTOP was a multicenter randomized study that compared ranibizumab with PDT in 93 patients with PCV. (35) Although both treatments improved central retinal thickness, intention-to-treat analysis at 12 months found ranibizumab to be superior to PDT for changes in visual acuity. Mean logMAR improved in the ranibizumab arm (from .48 to .39, gain of .9 lines), but remained unchanged in eyes treated with PDT (from .57 to .62, loss of .5 lines). In the ranibizumab arm 30.4% of patients achieved visual acuity gain (≥.2 logMAR) compared with 17.0% of patients treated with PDT.

The EVEREST Study:

EVEREST was a multicenter, double-masked comparison of PDT, ranibizumab, or both in 61 patients with PCV. (36) At 6 months, PDT alone or combined with ranibizumab was superior to ranibizumab monotherapy in achieving complete polyp regression (77.8%, 71.4%, 28.6%, respectively). In comparison, the proportion of patients gaining at least 15 letters was 21% for PDT plus ranibizumab, 19% for PDT alone, and 33.3% for ranibizumab monotherapy. The study was not powered to demonstrate statistically significant differences in BCVA between groups.

Clinical Input Received through Physician Specialty Societies and Academic Medical Centers

Blue Cross Blue Shield Association (BCBSA) received input from 1 physician specialty society and 2 academic medical centers in 2011. While the various physician specialty societies and academic medical centers may collaborate with and make recommendations during this process through the provision of appropriate reviewers, input received does not represent an endorsement or position statement by the physician specialty society or academic medical centers, unless otherwise noted. The input supported the use of anti-VEGF therapies (ranibizumab, bevacizumab, pegaptanib) for CNV due to AMD, angioid streaks, central serous chorioretinopathy, choroidal rupture or trauma, idiopathic choroidal neovascularization, pathologic myopia, presumed ocular histoplasmosis syndrome, and uveitis; clinical input did not uniformly support the use of anti-VEGF therapies for chorioretinal scars. The evidence provided in support of the medical necessity of anti-VEGF therapy for these conditions consisted of some small controlled trials and numerous case series.

Practice Guidelines and Position Statements

American Academy of Ophthalmology (AAO)

In 2014, the AAO issued AMD Preferred Practice Patterns. (37) The recommendations for the care of AMD include the following:

Intravitreal injection therapy using anti- VEGF agents (e.g., aflibercept, bevacizumab, and ranibizumab) is the most effective way to manage neovascular AMD and represents the first line of treatment.

Intravitreal anti-VEGF therapy is generally well-tolerated and rarely associated with serious AEs such as infectious endophthalmitis or retinal detachment. Symptoms suggestive of postinjection endophthalmitis or retinal detachment require prompt evaluation.

Canadian Agency for Drugs and Technologies in Health (CADTH)

In April 2008, the CADTH, released a Health Technology Assessment (HTA) titled Management of Neovascular Age-related Macular Degeneration: Systematic Drug Class Review and Economic Evaluation. The review of clinical evidence found that, with the exception of trials comparing ranibizumab with PDT, there was a significant lack of trials comparing the other anti-VEGF agents in general. The authors concluded that “…overall, the efficacy of anti-vascular endothelial growth factor (anti-VEGF) therapies over verteporfin (V-PDT) is well supported by RCTs. What remains unclear is whether combination therapy (and which combinations) are superior or equal to monotherapy. Furthermore the efficacy of one anti-VEGF agent compared with another is also unclear and this has very important practical and economic implications.” (38)

National Institute for Health and Care Excellence (NICE)

In 2012, the United Kingdom’s NICE modified their 2008 technology appraisal 155, which now recommends the use of ranibizumab for the treatment of wet AMD if all of the following conditions apply to the eye being treated: the BCVA is between 6/12 and 6/96, there is no permanent structural damage to the central fovea, the lesion size is less than or equal to the 12 disc areas in greatest linear dimension, there is evidence of recent presumed disease progression (blood vessel growth as indicated by fluorescein angiography) or recent visual acuity changes. Specified financial agreements with the manufacturer must also be in place. (39)

NICE issued Technology Assessment (TA) 294 in 2013 recommending the use of aflibercept only if it is used in accordance with their technology appraisal 155 for ranibizumab; specified financial agreements with the manufacturer must be in place. (40)

NICE issued TA 298 in 2013, which states that ranibizumab is recommended as a treatment option for visual impairment due to CNV secondary to pathologic myopia when the manufacturer provides ranibizumab at the agreed-on discount. (41)

Summary of Evidence

The available literature from RCTs supports the use of anti-VEGF therapies (ranibizumab, bevacizumab, pegaptanib, aflibercept) as monotherapy for the treatment of CNV associated with AMD. The use of anti-VEGF therapies for CNV secondary to other relatively rare disorders of choroidal circulation (angioid streaks, central serous chorioretinopathy, choroidal rupture or trauma, idiopathic CNV, multifocal choroiditis, pathologic myopia, presumed ocular histoplasmosis syndrome, and uveitis) is supported by a few small randomized trials, numerous case series, and BCBSA clinical input. Therefore, anti-VEGF therapies (ranibizumab, bevacizumab, pegaptanib, aflibercept) may be considered medically necessary for CNV associated with these conditions. Anti-VEGF therapies are considered experimental, investigational and/or unproven for the treatment of chorioretinal scars.

Contract:

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coding:

CODING:

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.

CPT/HCPCS/ICD-9/ICD-10 Codes

The following codes may be applicable to this Medical policy and may not be all inclusive.

CPT Codes

67028

HCPCS Codes

C9257, J0178, J2503, J2778, J3490, J9035

ICD-9 Diagnosis Codes

Refer to the ICD-9-CM manual

ICD-9 Procedure Codes

Refer to the ICD-9-CM manual

ICD-10 Diagnosis Codes

Refer to the ICD-10-CM manual

ICD-10 Procedure Codes

Refer to the ICD-10-CM manual


Medicare Coverage:

The information contained in this section is for informational purposes only. HCSC makes no representation as to the accuracy of this information. It is not to be used for claims adjudication for HCSC Plans.

The Centers for Medicare and Medicaid Services (CMS) does not have a national Medicare coverage position. Coverage may be subject to local carrier discretion.

A national coverage position for Medicare may have been developed since this medical policy document was written. See Medicare's National Coverage at <http://www.cms.hhs.gov>.

References:

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34. Gharbiya M, Giustolisi R, Allievi F, et al. Choroidal neovascularization in pathologic myopia: intravitreal ranibizumab versus bevacizumab--a randomized controlled trial. Am J Ophthalmol. Mar 2010; 149(3):458-64 e451. PMID 20172072

35. Oishi A, Kojima H, Mandai M, et al. Comparison of the effect of ranibizumab and verteporfin for polypoidal choroidal vasculopathy: 12-month LAPTOP study results. Am J Ophthalmol. Oct 2013; 156(4):644-51. PMID 23876867

36. Koh A, Lee WK, Chen LJ, et al. EVEREST study: efficacy and safety of verteporfin photodynamic therapy in combination with ranibizumab or alone versus ranibizumab monotherapy in patients with symptomatic macular polypoidal choroidal vasculopathy. Retina. Sep 2012; 32(8):1453-64. PMID 22426346

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48. FDA-U.S. Food and Drug Administration. Drug approval package for Macugen (pegaptanib sodium) injection. 2011. Available at <http://www.accessdata.fda.gov> (accessed on 2016 August 1).

Policy History:

DateReason
10/15/2017 Reviewed. No changes.
5/15/2017 Document updated with literature review. The following was added, “(CNV; includes myopic CNV or mCNV)”, to the “Intravitreal injection of anti-VEGF therapies may be considered medically necessary for the treatment of choroidal neovascularization” coverage statement.
9/15/2016 Document updated with literature review. Coverage unchanged.
8/15/2015 Document updated with literature review. Coverage unchanged.
10/1/2014 Document updated with literature review. The following was changed: 1) Intravitreal injection of anti-VEGF therapies may be considered medically necessary for the treatment of specifically listed choroidal vascular conditions; and 2) The treatment of chorioretinal scars was added to the anti-VEGF therapies considered experimental, investigational and/or unproven. The following was moved to other policies as follows: 1) Anti-VEGF therapies for treatment of retinal vascular disorders and can be found on OTH903.024; and 2) Verteporfin (Visudyne™) treatment in association with photodynamic therapy and can be found on OTH903.015. Anecortave acetate (Retaane™) was removed from the medical policy. CPT/HCPCS code(s) updated. The document was significantly revised and reorganized. Title changed from Anti-Vascular Endothelial Growth Factor (Anti-VEGF) Inhibitors for use in the Eye.
12/1/2012 Document partially updated with coverage change: Aflibercept injection (Eylea™) may be considered medically necessary for treatment macular edema following central retinal vein occlusion (CRVO). CPT/HCPCS code(s) updated.
10/15/2012 Document partially updated with coverage change: Lucentis may be considered medically necessary as an FDA labeled indication for the treatment of: diabetic macular edema. Rationale and References revised.
2/1/2012 Document partially updated with coverage change: FDA approval of Eylea™ (aflibercept) a new Anti-Vascular Endothelial Growth Factor (VEGF) was approved for intravitreal injection for neovascular (wet) age-related macular degeneration (ARMD or AMD). Rationale and References revised.
1/1/2011 The following change was made to Coverage: Lucentis may be considered medically necessary for the FDA labeled indication of macular retinal edema due to retinal vein occlusion. Age related macular edema (ARMD) was added under medically necessary indications for Avastin. Rationale and References were revised.
4/1/2010 Document updated with literature review. The following changes were made: Bevacizumab (Avastin™) may be considered medically necessary as a FDA off-labeled indication for the treatment of: choroidal (subretinal) neovascularization (e.g., secondary to aging macular degeneration, myopic degeneration, angioid streaks, idiopathic, secondary to toxoplasmosis, trauma, etc.); retinal neovascularization (e.g., secondary to diabetes, secondary to central retinal vein occlusion (CRVO), etc.). macular retinal edema due to diabetes mellitus, central retinal vein occlusion (CRVO) and/or branch retinal vein occlusion (BRVO); other neovascular conditions of the eye (e.g., rubeosis iridis, trabecular angle neovascularization, etc.). All other ophthalmologic uses of Bevacizumab remain experimental, investigational and unproven
9/1/2009 Coverage changed to address all Anti-VEGF treatments for the eye. Title has been changed from Neovascular Wet Age-Related Macular Degeneration (ARMD or AMD). Diabetic Retinopathy is now an off-label indication for Macugen®. Avastin™ is now indicated as off-label for diabetic macular edema, diabetic retinopathy, and macular retinal edema due to central retinal vein occlusion.
3/1/2009 Coverage Revised
12/15/2008 Coverage Revised
4/15/2008 Coverage Revised
1/1/2008 Codes Revised/Added Deleted
7/15/2007 Revised/Updated Entire Document
12/1/2003 New Medical Document

Archived Document(s):

Title:Effective Date:End Date:
Intravitreal Angiogenesis Inhibitors for Choroidal Vascular Conditions04-01-202207-14-2022
Intravitreal Angiogenesis Inhibitors for Choroidal Vascular Conditions02-01-202203-31-2022
Intravitreal Angiogenesis Inhibitors for Choroidal Vascular Conditions12-15-202001-31-2022
Intravitreal Angiogenesis Inhibitors for Choroidal Vascular Conditions02-15-201912-14-2020
Intravitreal Angiogenesis Inhibitors for Choroidal Vascular Conditions10-15-201702-14-2019
Intravitreal Angiogenesis Inhibitors for Choroidal Vascular Conditions05-15-201710-14-2017
Intravitreal Angiogenesis Inhibitors for Choroidal Vascular Conditions09-15-201605-14-2017
Intravitreal Angiogenesis Inhibitors for Choroidal Vascular Conditions08-15-201509-14-2016
Intravitreal Angiogenesis Inhibitors for Choroidal Vascular Conditions10-01-201408-14-2015
Anti-Vascular Endothelial Growth Factor (VEGF) Inhibitors for use in the Eye12-01-201209-30-2014
Anti-Vascular Endothelial Growth Factor (VEGF) Inhibitors for use in the Eye10-15-201211-30-2012
Anti-Vascular Endothelial Growth Factor (VEGF) Inhibitors for use in the Eye02-01-201210-14-2012
Anti-Vascular Endothelial Growth Factor (VEGF) Inhibitors for use in the Eye01-01-201101-31-2012
Anti-Vascular Endothelial Growth Factor (VEGF) Inhibitors for use in the Eye04-01-201012-31-2010
Anti-Vascular Endothelial Growth Factor (VEGF) Inhibitors for use in the Eye09-01-200903-31-2010
Neovascular Wet Age-Related Macular Degeneration (ARMD or AMD)03-01-200908-31-2009
Neovascular Wet Age-Related Macular Degeneration (ARMD or AMD)12-15-200802-28-2009
Neovascular Wet Age-Related Macular Degeneration (ARMD or AMD)04-15-200812-14-2008
Neovascular (Wet) Age-Related Macular Degeneration (ARMD or AMD)07-15-200704-14-2008
Conjunctival Incision with Posterior Juxtascleral Placement of Anecortave Acetate Depot Suspension01-01-200607-14-2007
Pegaptanib Sodium Injection (Macugen�) for Age-Related Macular Degeneration (ARMD or AMD)10-15-200507-14-2007
Pegaptanib Sodium Injection (Macugen) for Age-Related Macular Degeneration (ARMD or AMD)07-08-200510-14-2005
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