Does H35.3210 require prior authorization?

No, H35.3210 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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`H35.3210`, Exudative age-related macular degeneration, right eye, stage unspecified

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).

20 Active Policies

CGS-J15-L38992, Electroretinography (ERG)

J15

CGS-J18-L38992, Electroretinography (ERG)

J18

WPS-J5-L37015, Visual Electrophysiology Testing

A57599, Billing and Coding: Visual Electrophysiology Testing

A56916, Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

WPS-J5-L34760, Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

A52451, Billing and Coding: Ranibizumab and biosimilars, Aflibercept, Aflibercept HD, Brolucizumab-dbll, Faricimab-svoa, PAVBLUaflibercept-ayyh, AHZANTIVEaflibercept-abzv. ENZEEVUaflibercept-mrbb, OPUVIZaflibercept-yszy and YESAFILI aflibercept-jbvf

A56726, Billing and Coding: Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)

NGS-J6-L36831, Visual Electrophysiology Testing

NGS-J6-L34380, Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

A57060, Billing and Coding: Visual Electrophysiology Testing

NGS-J6-L33574, Visual Fields Testing

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

A52370, Billing and Coding: Bevacizumab and biosimilars

NGS-J6-L33567, Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)

A56537, Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

A56551, Billing and Coding: Visual Fields Testing

WPS-J8-L37015, Visual Electrophysiology Testing

WPS-J8-L34760, Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

FIRST_COAST-L37398, Electroretinography (ERG)

`H35.3210`, Exudative age-related macular degeneration, right eye, stage unspecified

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

H35.3210, Exudative age-related macular degeneration, right eye, stage unspecified

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`H35.3210`, Exudative age-related macular degeneration, right eye, stage unspecified