Title: Ranibizumab for Age-related Macular Degeneration
Abstract: We read with interest the article by Gupta et al1Gupta O.P. Shienbaum G. Patel A.H. et al.A treat and extend regimen using ranibizumab for neovascular age-related macular degeneration clinical and economic impact.Ophthalmology. 2010; 117: 2134-2140Abstract Full Text Full Text PDF PubMed Scopus (255) Google Scholar evaluating the “treat and extend” (TER) regimen for intravitreal ranibizumab therapy for neovascular age-related macular degeneration (nAMD) and comparing the cost of this treatment method with the standard treatment modality of monthly injections as evaluated by the ANCHOR (Anti-VEGF Antibody for the Treatment of Predominantly Classic Choroidal in Age-related Macular Degeneration) and MARINA (Minimally Classic/Occult Trial of the Anti-VEGF Antibody Ranibizumab in the Treatment of Neovascular Age-Related Macular Degeneration) trials.2Brown D.M. Kaiser P.K. Michels M. et al.ANCHOR Study GroupRanibizumab versus verteporfin for neovascular age-related macular degeneration.N Engl J Med. 2006; 355: 1432-1444Crossref PubMed Scopus (3040) Google Scholar, 3Rosenfeld P.J. Brown D.M. Heier J.S. et al.MARINA Study GroupRanibizumab for neovascular age-related macular degeneration.N Engl J Med. 2006; 355: 1419-1431Crossref PubMed Scopus (4840) Google Scholar We agree that the TER strategy seems to offer a reasonable approach for treating nAMD with fewer injections and at a lower cost than monthly injections. We have identified an error in the economic analysis presented in their manuscript. Specifically, when calculating the cost of 1 year of treatment as described by the MARINA and ANCHOR trials, the authors included the cost of an examination at each monthly injection visit. However, in both the MARINA and ANCHOR trials, injections were provided monthly to enrolled patients regardless of clinical examination. According to the Centers for Medicare and Medicaid Services4Medicare Claims Processing Manual.http://www.cms.gov/manuals/downloads/clm104c12.pdfGoogle Scholar it is unlawful to bill for an ophthalmic examination and procedure (intravitreal injection or otherwise) on the same clinic visit unless the examination that day was used to determine if that procedure was appropriate or necessary (in which case, a -25 modifier would be necessary for billing purposes). If a patient returns to clinic explicitly for an injection, you cannot bill for an examination. In the case of the MARINA and ANCHOR trials, all study costs were paid for by the study sponsors. A practice pattern modeled on these studies, however, could not include the costs of the monthly ophthalmic examination because injections were performed regardless of clinical examination findings. The aforementioned notwithstanding, a modified total for the annual medical cost per patient receiving injections per the ANCHOR and MARINA protocols that does not include the cost of monthly examinations is only $827.53 (or about 3%) less than that reported by Gupta et al. Therefore, even with this correction, the TER regimen as presented by the authors remains significantly less expensive than monthly injections. A Treat and Extend Regimen Using Ranibizumab for Neovascular Age-Related Macular Degeneration: Clinical and Economic ImpactOphthalmologyVol. 117Issue 11PreviewTo evaluate the visual outcome, number of injections, and direct medical cost of a “treat and extend” regimen (TER) in managing neovascular age-related macular degeneration (nAMD) with intravitreal ranibizumab. Full-Text PDF Author replyOphthalmologyVol. 118Issue 8PreviewWe appreciate the interest in our paper from Drs. Seider and Stewart.1 If every follow-up examination over the first year was not billable because it was bundled with the planned monthly injections, as suggested by Drs. Seider and Stewart, then the minimum adjusted total cost would be $27 486.63 instead of $28 314.16. However, in reality, there are often distinct medical issues associated with neovascular age-related macular degeneration (nAMD) or with its treatment that involves a separate evaluation and management encounter. Full-Text PDF