Does E11.A require prior authorization?

No, E11.A does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

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`E11.A`, Type 2 diabetes mellitus without complications in remission

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization by at least one policy, though another does not cover it (medium confidence)

Documentation Required

The intravitreal injection procedure must be coded using CPT code 67028 and the appropriate RT, LT, or 50 site modifier must be appended to indicate unilateral or bilateral service.
Dose and frequency for bevacizumab and biosimilars must follow the FDA label or recognized compendia for off-label uses; compendia cited include AHFS, Clinical Pharmacology, Lexi-Drugs, Micromedex DrugDex, NCCN, FDA, and USP.
When billing for metastatic (secondary) disease, use the code for the primary malignancy if the primary tumor is still present, and use the appropriate personal history 'Z' code if the primary malignancy is no longer present.

Key Coverage Criteria

For non-ophthalmologic (systemic) use, bevacizumab must be reported with HCPCS code J9035 (injection, bevacizumab, 10 mg) with units reflecting multiples of 10 mg provided.
For non-ophthalmologic use, bevacizumab-awwb (MVASI) must be reported with HCPCS code Q5107 (10 mg).
For non-ophthalmologic use, bevacizumab-bvzr (ZIRABEV) must be reported with HCPCS code Q5118 (10 mg).
Bevacizumab-maly (ALYMSYS/ALYMSYS1) is reported with HCPCS code C9142 for 10/01/2022–12/31/2022 and with HCPCS code Q5126 effective 01/01/2023 (10 mg).
Bevacizumab-adcd (Vegzelma) should be reported with HCPCS code Q5129 effective 04/01/2023.
For the period 09/27/2022 through 03/31/2023 bevacizumab-maly could be reported with miscellaneous code J3590 (per guidance for that timeframe).

12 Active Policies

A56232, Billing and Coding: Foot Care

A56544, Billing and Coding: Cataract Extraction

NGS-J6-L33394, Drugs and Biologicals, Coverage of, for Label and Off-Label Uses

NGS-J6-L33558, Cataract Extraction

A52370, Billing and Coding: Bevacizumab and biosimilars

NGS-JK-L33558, Cataract Extraction

NGS-JK-L33394, Drugs and Biologicals, Coverage of, for Label and Off-Label Uses

ANTHEM-CG-DME-50, Automated Insulin Delivery Systems

ANTHEM-MP-A070096, TRANS.00034 Hematopoietic Stem Cell Transplantation for Diabetes Mellitus

ANTHEM-CG-MED-35, Retinal Telescreening Systems

ANTHEM-CG-DME-19, Therapeutic Shoes, Inserts, or Modifications for Individuals with Diabetes

ANTHEM-CG-MED-73, Hyperbaric Oxygen Therapy (Systemic/Topical)

`E11.A`, Type 2 diabetes mellitus without complications in remission

Prior Authorization

Documentation Required

Key Coverage Criteria

12 Active Policies

Related Codes

Have a follow-up question?

E11.A, Type 2 diabetes mellitus without complications in remission

Prior Authorization

Documentation Required

Key Coverage Criteria

12 Active Policies

Related Codes

Have a follow-up question?

`E11.A`, Type 2 diabetes mellitus without complications in remission