Is Avastin (bevacizumab) 10mg injection medically necessary for a patient with posterior vitreous detachment, central retinal vein occlusion, and symptoms of blurred vision, foreign body sensation, photophobia, and dryness?

Bevacizumab (Avastin) is NOT Medically Necessary for This Patient

The requested bevacizumab injections should be denied because posterior vitreous detachment (PVD) is not an approved indication for anti-VEGF therapy, and the patient's clinical presentation does not meet established treatment criteria.

Rationale for Denial

Primary Diagnosis Does Not Support Treatment

• Posterior vitreous detachment is a benign, self-limited condition that does not require bevacizumab treatment 1, 2
• PVD represents a normal age-related separation of the vitreous cortex from the retina and is not characterized by pathologic neovascularization or macular edema that would respond to anti-VEGF therapy 1
• The American Academy of Ophthalmology guidelines for PVD management focus on observation and monitoring for retinal breaks, not pharmacologic intervention 1, 2

Secondary Diagnosis Requires Different Evaluation

• While the patient carries a diagnosis of central retinal vein occlusion (CRVO) with retinal neovascularization (H34.8111), the clinical documentation describes only PVD findings without evidence of active macular edema or neovascularization requiring treatment 1
• Bevacizumab is indicated for macular edema following retinal vein occlusion, but the clinical notes document "flashes/floaters x1 week" with "no signs of tears or detachments" - findings consistent with uncomplicated PVD, not active CRVO complications 1, 3

MCG Criteria Not Met

The case explicitly states the patient does NOT meet the required MCG criteria:

• The patient does not have diabetic macular edema 1
• The patient does not have documented macular edema following retinal vein occlusion requiring treatment 1, 3
• The patient does not have myopic choroidal neovascularization 1
• The patient does not have neovascular age-related macular degeneration 4

Documented Symptoms Are Consistent with PVD, Not VEGF-Mediated Disease

• Blurred vision, foreign body sensation, photophobia, and dryness are common symptoms of acute PVD and do not indicate pathologic neovascularization 1, 2
• The examination findings of "1+ Nuclear sclerosis" and "Posterior vitreous detachment" without documented macular edema, subretinal fluid, or active neovascularization further support that anti-VEGF therapy is inappropriate 1

Appropriate Management for This Patient

Standard of Care for Uncomplicated PVD

• Observation with return precautions is the appropriate management for patients with acute PVD and no retinal breaks 1, 2
• Selected patients should return for re-examination within 6 weeks following onset of PVD symptoms, particularly those with vitreous pigment, hemorrhage, or visible vitreoretinal traction 1
• Between 5-14% of patients with initial retinal breaks develop additional breaks during long-term follow-up, necessitating surveillance rather than prophylactic treatment 1, 2

If CRVO With Macular Edema Were Present

• Only if the patient had documented center-involving macular edema on OCT would anti-VEGF therapy be indicated 1, 3
• Treatment would require objective evidence of macular edema with central subfield thickness measurements and visual acuity documentation 1
• The current documentation lacks OCT measurements of macular thickness or evidence of fluid accumulation 1

Critical Documentation Deficiencies

• No OCT imaging documenting macular edema or subretinal fluid
• No fluorescein angiography demonstrating active neovascularization or leakage
• No visual acuity measurements using standardized testing
• Clinical examination describes only PVD findings without pathologic features requiring anti-VEGF intervention 1, 2

Common Pitfall Avoided

The presence of a CRVO diagnosis code does not automatically justify bevacizumab treatment - the patient must have active, documented complications of CRVO (specifically macular edema or neovascularization) that are amenable to anti-VEGF therapy 1, 3. The clinical presentation described is entirely consistent with uncomplicated PVD, which requires observation, not pharmacologic intervention 1, 2.