Ophthalmology Prior Authorization and Denial Guide
Prior authorization requirements, denial patterns, and appeal frameworks for anti-VEGF injections, cataract surgery, blepharoplasty, and glaucoma procedures. Grounded in Aetna CPB #0701 (VEGF Inhibitors), CPB #0508 (Cataract Surgery), CPB #0084 (Blepharoplasty), UHC CDG Ophthalmology, CMS LCD L36962 for cataract surgery, CMS NCD 80.12, and AAO Preferred Practice Patterns.
Anti-VEGF injections: intravitreal injections of ranibizumab (CPT J2778), bevacizumab (J9035), aflibercept (J0178), and faricimab (J3490) require prior authorization for wet AMD, diabetic macular edema, and retinal vein occlusion. Aetna CPB #0701 specifies coverage criteria including confirmed diagnosis by fluorescein angiography or OCT, visual acuity documentation, and for some indications, prior bevacizumab trial before branded agents. Most commercial payers cover bevacizumab (off-label) as the first-line agent for wet AMD and DME — step therapy to branded agents (aflibercept, ranibizumab) typically requires inadequate response to bevacizumab.
Cataract surgery: Medicare covers cataract extraction when visual acuity is documented as 20/40 or worse in the operative eye and the cataract is causing functional visual impairment. Commercial payers follow similar visual acuity thresholds. Functional blepharoplasty (CPT 15823) requires prior authorization with documentation of dermatochalasis causing visual field restriction of ≥30° and clinical photographs showing the eyelid obstruction. Visual field testing with and without lid taped is required by most payers. Cosmetic blepharoplasty is excluded from coverage.