The Academy successfully advocated to overturn a WellMed step therapy policy for noninfectious uveitis. The policy had required a three-month failure of repackaged bevacizumab (Avastin), a drug that does not even treat uveitis, before a patient could get Ozurdex, an FDA-indicated therapy for the condition. After reviewing its policy in response to our letter, the insurer revised its coverage criteria language.
A senior staff person with WellMed contacted the Academy on Wednesday with the changes.
WellMed’s Updated Policy
The insurer’s updated 039.00S Coverage Determination Policy for lntravitreal Implants now states:
- WellMed Medical Management will cover Ozurdex (dexamethasone) as medically necessary for the treatment of noninfectious posterior uveitis when ALL of the following criteria are met:
- a) No documentation of active ophthalmic infection noted by provider.
- b) The patient does not have glaucoma with a cup-to-disc ratio of greater than 0.8.
- c) Patient has an intolerance, contraindication or treatment failure to a 28-days course of therapy of first-line pharmacologic therapy or systemic immunosuppressive agents (corticosteroids or anti-tumor necrosis factor inhibitors like Humira) that has not resulted in a clinical improvement or positive response of the inflammation or edema.
Although WellMed still requires a step before allowing Ozurdex, it's not a three-month failure of a drug that doesn't even treat noninfectious uveitis.
“We are pleased that WellMed took this seriously from the start, kept the Academy updated along the way and made an appropriate policy change after making a thorough review,” said George A. Williams, MD, the Academy’s senior secretary for advocacy.
He also said that “anti-TNF treatments like Humira (adalimumab) actually do have an indication for uveitis. And although other corticosteroids may be less effective than Ozurdex, they are not clinically inappropriate like Avastin.”
How the Problem Surfaced and What the Academy Did
The Academy contacted the Medicare Advantage plan in September after a Texas ophthalmology practice alerted us that WellMed required its patient to fail three months of treatment on Avastin before trying Ozurdex. However, there is no evidence that Avastin helps patients with uveitis.
It appears that a WellMed policy revision earlier this year added the Avastin requirement — despite the policy’s detailed drug option section providing no clinical support for ocular use of this treatment.
The Academy vehemently opposes step therapy requirements. These policies take clinical decision-making out of your hands, interfere in the physician-patient relationship and can harm patients through inappropriate or delayed treatment. They also create administrative burdens you shouldn’t have to deal with.
We included this example in a Sept. 23 meeting with the Centers for Medicare & Medicaid Services to address step therapy requirements.
This case highlights how important it is to alert the Academy when you encounter policy issues that affect your patients and practice.
If you have a claim denial or treatment requirement that departs from standard practice,
you can reach out to healthpolicy@aao.org.