Does J2779 require prior authorization?

Yes, J2779 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for J2779?

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

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`J2779`, Injection, ranibizumab, via intravitreal implant (susvimo), 0.1 mg

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires 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).

For Part A and Part B MAC claims, report the drug using the specified HCPCS/J-codes or Q-codes as listed by product (e.g., ranibizumab J2778/J2779 or Q5124/Q5128, aflibercept J0178 or J0177/Q-codes for biosimilars, brolucizumab-dbll J0179, faricimab-svoa J2777).

Coverage determinations for off-label use require supporting peer-reviewed literature, specialty consultant advice as indicated, and reference to accepted standards of medical practice; documentation of these sources must be provided for review.

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 requires a diagnosis of neovascular AMD, DME, or DR with prior response to at least two VEGF inhibitor intravitreal injections, dosing per FDA labeling, and initial authorization ≤12 months. For continuation, must have positive clinical response, dosing per FDA labeling, and authorization ≤12 months.
Treatment of patients with Neovascular (wet) Age-related Macular Degeneration (AMD) who have previously responded to at least two intravitreal injections of a Vascular Endothelial Growth Factor (VEGF) inhibitor medication. (FDA‑approved indication)
Intravitreal ranibizumab (Lucentis/Byooviz/Cimerli) may be considered medically necessary for diabetic macular edema (DME).
Intravitreal ranibizumab (Lucentis/Byooviz/Cimerli) may be considered medically necessary for diabetic retinopathy (DR).
Intravitreal ranibizumab (Lucentis/Byooviz/Cimerli) may be considered medically necessary for macular edema following central retinal vein occlusion (CRVO).

17 Active Policies

ARKBLUE-RANIBIZUMAB-E-G-SUSVIMO-650BA9DA2C, Ranibizumab (e.g., Susvimo)

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

HEALTHNET_OR-HNOR-RANIBIZUMAB-BYOOVIZ-CIMERLI-LUCENTIS-NUFYMCO-SUSVIMO-CP-32A05AF835, Ranibizumab (Byooviz, Cimerli, Lucentis, Nufymco, Susvimo); CP.PHAR.186

MODA-SUSVIMO-D24BE73DAA, Susvimo (ranibizumab)

UMR-POL-UMR-susvimo, Susvimo (Ranibizumab Injection)

SUREST-POL-SUREST-susvimo, Susvimo (Ranibizumab Injection)

BCBSTN-be95db2d1e, Ranibizumab (Susvimo)

EVICORE-MEDICAL_DRUG-D9E341F0B200, Susvimo (ranibizumab intravitreal injection via ocular implant)

ANTHEM-SURG.00160, Implanted Port Delivery Systems to Treat Ocular Disease

UHC-EXCH-MD-SUSVIMO-RANIBIZUMAB-INJECTION-COMMERCIAL-166E1A2497, Susvimo (Ranibizumab Injection) – Commercial and Individual Exchange Medical Benefit Drug Policy

UHC-POL-susvimo, Susvimo (Ranibizumab Injection)

BCBSIL-OTH903.041, Ranibizumab Injections, Implants and Biosimilars

BCBSMT-OTH903.041, Ranibizumab Injections, Implants and Biosimilars

BCBSNM-OTH903.041, Ranibizumab Injections, Implants and Biosimilars

BCBSOK-OTH903.041, Ranibizumab Injections, Implants and Biosimilars

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J2779, Injection, ranibizumab, via intravitreal implant (susvimo), 0.1 mg