Medicare Trends in Intravitreal Anti-VEGF Use: A Population-Based Study (2014-2023)

To characterize national trends, reimbursement patterns, and geographic variation in intravitreal anti-vascular endothelial growth factor (anti-VEGF) use among Medicare beneficiaries from 2014 to 2023. Retrospective cross-sectional study. All Medicare Part B fee-for-service beneficiaries receiving intravitreal anti-VEGF injections billed by ophthalmologists in the United States. The Centers for Medicare & Medicaid Services (CMS) Physician and Other Supplier Public Use File was used to identify intravitreal anti-VEGF injections administered between January 1, 2014, and December 31, 2023. Agents included aflibercept, ranibizumab, bevacizumab, brolucizumab, and faricimab, identified using Healthcare Common Procedure Coding System (HCPCS) codes. Service units were converted to injection counts using drug-specific dosing information. Longitudinal trends were assessed using the Mann–Kendall test. Annual intravitreal injection counts, number of unique Medicare beneficiaries receiving each agent, standardized Medicare reimbursement per injection, and state-level utilization rates per 100,000 beneficiaries. From 2014 to 2023, a total of 36,398,293 intravitreal anti-VEGF injections were administered to Medicare beneficiaries. Aflibercept use increased significantly (618,796 injections in 2014 vs 1,713,729 in 2023; τ = 0.91; p<0.001). Ranibizumab (808,890 vs 388,600; τ = -0.16; p<0.59), bevacizumab (1,202,334 vs 1,450,034; τ = -0.07; p<0.86), and brolucizumab (45,861 in 2019 vs 5,381 in 2023; τ = -1.00; p<0.09) showed no significant monotonic trends. Faricimab demonstrated rapid early uptake following its introduction in 2022 (65,052 to 556,512 injections). Standardized Medicare reimbursement per injection declined significantly for ranibizumab ($1,234.35 to $724.74; τ = -1.00; p<.001) and aflibercept ($1,527.37 to $1,379.54; τ = -0.82; P = .001), remained stable for brolucizumab, and increased for bevacizumab ($46.76 to $300.73; τ = 0.69; p<.01). In 2023, state-level utilization varied by up to 31.6-fold, from 5,723 per 100,000 beneficiaries in West Virginia to 180,838 per 100,000 in Alaska. Intravitreal anti-VEGF utilization among Medicare beneficiaries increased substantially from 2014 to 2023, driven primarily by growth in aflibercept use and rapid adoption of faricimab. Reimbursement for certain branded agents declined over time, while substantial geographic variation in injection rates persisted across states. Continued monitoring is warranted as biosimilars, emerging agents, and novel delivery systems enter the U.S. market.