Archived Policies - Other
Ocriplasmin for Symptomatic Vitreomacular Adhesion (VMA)
A single intravitreal injection of ocriplasmin may be considered medically necessary for treatment of an eye with symptomatic vitreomacular adhesion (VMA), when the following criteria have been met:
The use of intravitreal ocriplasmin is considered experimental, investigational and/or unproven in all other situations, including use of repeat injections of ocriplasmin.
The vitreous is a gel-like fluid within the eye that adheres completely to the surface of the retina. The consistency of the vitreous and its adhesion to the retina are maintained by several proteins including collagen, laminin, and fibronectin. With aging, the proteins in the vitreous break down, resulting in liquefaction of the vitreous and eventual separation of the vitreous from the retina, a process called posterior vitreous detachment (PVD).
The process of vitreous detachment usually proceeds without incident, but sometimes the separation is not complete. The adhesion usually remains at sites where the bonds between the vitreous and retina are the strongest. Adhesion at the macula is called vitreomacular adhesion (VMA). In some cases, VMA can cause visual symptoms. The traction caused by the adherent vitreous can cause deformation of the retina, edema, and macular holes. The retina may tear or detach. Symptoms can be variable, but can include diminished visual acuity, distorted vision (metamorphopsia) and central field defect.
Patients are usually observed until resolution or worsening, in which case vitrectomy is the only treatment. Although it is believed that only 10% of cases resolve spontaneously, observation is usually indicated because vitrectomy has risks and an almost certain occurrence of cataract in the years following vitrectomy. (1, 2)
Ocriplasmin (Jetrea®) is a recombinant product that is a shortened/truncated form of the human protease plasmin that breaks down protein components at the vitreoretinal interface in the eye. Ocriplasmin is injected into the affected eye (intravitreal) as a single dose and can induce vitreous liquefaction and separation from the retina. Its proposed use is for the treatment of symptomatic VMA. Early studies of ocriplasmin were conducted in patients who were scheduled to have vitrectomy and established doses that showed some effect in inducing PVD and the temporal course of the effect. Studies by Benz et al., de Smet et al., and Stalmans et al. led to the design and conduct of the pivotal clinical trials described in the Rationale section of this medical policy. (3-5)
Ocriplasmin (Jetrea®, ThromboGenics Inc., Iselin, NJ) received U.S. Food and Drug Administration (FDA) approval October 17, 2012 for the treatment of symptomatic VMA. There were no contraindications noted. In the Warnings and Precautions section of the prescribing information, it was noted that a higher percentage of subjects treated with ocriplasmin in the clinical trials had worsening of visual acuity of 3 or more lines than subjects in the control group. Transient injection-associated effects such as inflammation occurred in a higher percentage of subjects treated with ocriplasmin than control subjects.
This medical policy was created in January 2013, with literature review covering the period up to December 2013. The medical policy is based on a 2013 Blue Cross Blue Shield Association (BCBSA) Technology Evaluation Center (TEC) Assessment, (6) which included 2 randomized controlled trials (RCTs) of ocriplasmin versus standard treatment, and summarized the findings of these trials as follows:
Conclusion: The one large RCT of ocriplasmin shows that ocriplasmin is associated with higher rates of resolution of VMAs, closure of macular holes, lower rates of vitrectomy and improvement in some measures of visual acuity, without increases in major adverse events, when compared to watchful waiting with vitrectomy as indicated. This demonstrates improvement in health outcomes.
The principal evidence supporting ocriplasmin for symptomatic VMAs is the published study by Stalmans et al. (7) The study presents pooled results of 2 identically designed double-blind placebo-RCTs. Patients enrolled in the study met strict inclusion and exclusion criteria listed in the coverage statement. They were not currently scheduled to have vitrectomy, but according to assessment by their physician, 84% were expected to need vitrectomy if their condition did not improve. Overall, 652 eyes were treated; 464 with ocriplasmin and 188 with placebo. The principal endpoint of the study, resolution of VMAs at 28 days, occurred in 26.5% of ocriplasmin-treated patients and 10.1% of placebo-treated patients. Other 28-day secondary endpoints, posterior vitreal detachment and closure of macular holes, also favored ocriplasmin.
Secondary outcomes measured beyond 28 days were also better in ocriplasmin-treated eyes. By 6 months, 17.7% of ocriplasmin-treated subjects had undergone vitrectomy versus 26.6% of placebo-treated subjects. Visual improvement results varied depending on how the data were analyzed, but generally favored ocriplasmin. Measured as categorical improvement of 3 or more lines on the Early Treatment of Diabetic Retinopathy (ETDRS) chart, ocriplasmin-treated subjects had higher success rates than placebo-treated subjects. Absolute gains in both groups were modest, particularly in the analysis where improvement was only counted in those who did not undergo vitrectomy (9.7% and 3.7%, respectively).
Major adverse events were not significantly different between the 2 groups. The most common side effects reported in individuals treated with ocriplasmin include eye floaters; bleeding of the conjunctiva, eye pain; flashes of light (photopsia); blurred vision; vision loss; retinal edema (swelling); and macular edema.
Conclusions: This clinical trial of ocriplasmin in patients with symptomatic VMAs demonstrates that it resolves VMAs and lessens the need for vitrectomy in a proportion of patients, although some patients resolve VMA without ocriplasmin and vitrectomy is still needed in some patients despite treatment with ocriplasmin.
Ocriplasmin is a novel treatment for VMAs. One large double-blind placebo-RCT and other earlier supporting studies demonstrate that ocriplasmin resolves VMAs and prevents the need for vitrectomy in a proportion of the patients treated, without a higher rate of important complications. Improvements in visual acuity are modest. Therefore, ocriplasmin may be considered medically necessary for the treatment of symptomatic VMAs when clinical criteria are met.
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.
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.
The following codes may be applicable to this Medical policy and may not be all inclusive.
ICD-9 Diagnosis Codes
ICD-9 Procedure Codes
ICD-10 Diagnosis Codes
ICD-10 Procedure Codes
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.
1/1/2014 New medical document. A single intravitreal injection of ocriplasmin may be considered medically necessary for treatment of an eye with symptomatic vitreomacular adhesion (VMA), when specified clinical criteria has been met. Otherwise, the use of intravitreal ocriplasmin is considered experimental, investigational and/or unproven in all other situations, including use of repeat injections of ocriplasmin.
|Title:||Effective Date:||End Date:|
|Ocriplasmin for Symptomatic Vitreomacular Adhesion||07-15-2017||09-30-2018|
|Ocriplasmin for Symptomatic Vitreomacular Adhesion||08-01-2016||07-14-2017|
|Ocriplasmin for Symptomatic Vitreomacular Adhesion (VMA)||11-01-2015||07-31-2016|
|Ocriplasmin for Symptomatic Vitreomacular Adhesion (VMA)||01-01-2014||10-31-2015|