Does J0179 require prior authorization?

No, J0179 does not require prior authorization (high confidence). Covered without prior authorization.

What is the Medicare reimbursement rate for J0179?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`J0179`, Injection, brolucizumab-dbll, 1 mg

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

Medical record must document indication, route (intravitreal), dose and dosing frequency consistent with the FDA label or include literature support when dosing/frequency deviates from the FDA label.
The intravitreal administration must be billed with CPT 67028 on the same claim as the drug (or CPT 67027 for SUSVIMO) and must include the appropriate site modifier (RT, LT, or 50).

Provider requests to add an off-label use must be submitted in writing with supporting data consisting of either at least two Phase III trials demonstrating safety and effectiveness, or if no Phase III evidence exists, at least two large Phase II trials from different centers or other overwhelming Phase II evidence for rare diseases.

Key Coverage Criteria

Intravitreal administration of ranibizumab (including ranibizumab-nuna and ranibizumab-eqrn), aflibercept (including aflibercept HD and biosimilars PAVBLU™, AHZANTIVE®, ENZEEVU™, OPUVIZ™, YESAFILI™), brolucizumab-dbll, and faricimab-svoa is covered when used consistent with the FDA-approved package insert or supported compendia/literature for off-label uses.
Initial therapy for ophthalmologic VEGF/Ang-2 inhibitors requires (1) diagnosis, (2) intravitreal VEGF or dual VEGF/Ang-2 inhibitor administration limited to 12 doses per year per eye, and (3) authorization for a maximum of 12 months.
Eylea (aflibercept) is proven and medically necessary for diabetic macular edema, diabetic retinopathy, macular edema following retinal vein occlusion, neovascular age-related macular degeneration, and retinopathy of prematurity.
Beovu intravitreal injections may be medically necessary for diabetic macular edema or neovascular (wet) age-related macular degeneration.
Beovu may be medically necessary for diabetic macular edema.
Beovu may be medically necessary for neovascular (wet) AMD.

10 Active Policies

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

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

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

BCBSNM-OTH903.043, Brolucizumab-dbll

BCBSOK-OTH903.043, Brolucizumab-dbll

UMR-POL-UMR-ophthalmologic-vegf-inhibitors, Ophthalmologic Vascular Endothelial Growth Factor (VEGF) Inhibitors

SUREST-POL-SUREST-ophthalmologic-vegf-inhibitors, Ophthalmologic Vascular Endothelial Growth Factor (VEGF) Inhibitors

UHC-POL-ophthalmologic-vegf-inhibitors, Ophthalmologic Vascular Endothelial Growth Factor (VEGF) Inhibitors

BCBSIL-OTH903.043, Brolucizumab-dbll

BCBSMT-OTH903.043, Brolucizumab-dbll

`J0179`, Injection, brolucizumab-dbll, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

10 Active Policies

Related Codes

Have a follow-up question?

J0179, Injection, brolucizumab-dbll, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

10 Active Policies

Related Codes

Have a follow-up question?

`J0179`, Injection, brolucizumab-dbll, 1 mg