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ICD-10-CM H36.819, Nonproliferative sickle-cell retinopathy, unspecified eye | No Prior Auth

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`H36.819`, Nonproliferative sickle-cell retinopathy, unspecified eye

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Explicit clinical documentation is required to justify any treatment frequency that is more frequent than approximately every 4 weeks in a given eye.
For Part B claims, enter 'Intravitreal bevacizumab, [dose] mg' in Item 19 of the CMS-1500 or in Loop 2300/2400 NTE01 (NTE, 02) for electronic claims.
When billing J7999, enter '1' in the days/units field for one eye or '2' if both eyes are treated in the same encounter.
When billing CPT 67028, use modifier RT or LT to indicate the eye treated; if billing bilateral use modifier 50.

Key Coverage Criteria

When intravitreal bevacizumab is acquired from a compounding source or compounded in the physician's facility/office, bill using HCPCS J7999 on claims.
HCPCS J7999 shall be used for all compounded injectable drugs (not restricted to bevacizumab).
For Part A claims for intravitreal compounded bevacizumab, bill using HCPCS C9257 and provide the number of units.
Use scanning computerized ophthalmic diagnostic imaging (CPT 92134) at 4–6 week intervals when appropriate to evaluate need for re-treatment.

1 Active Policy

A53008, Billing and Coding: Intraocular Bevacizumab

Related Codes

92134(1 policies)B39.4(1 policies)B39.5(1 policies)B39.9(1 policies)C9257(1 policies)E08.311(1 policies)E08.319(1 policies)67028(1 policies)

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Physicians must provide and file appropriate informed consent for the off-label use of bevacizumab and retain it in the patient chart.

Medical records must be maintained and are subject to post-payment review; records must be submitted to Noridian or other Medicare authorized agency if requested.