Does J3299 require prior authorization?

Yes, J3299 requires prior authorization (medium confidence). Conditional coverage; review criteria to confirm PA need.

What is the Medicare reimbursement rate for J3299?

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

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`J3299`, Injection, triamcinolone acetonide (xipere), 1 mg

HCPCS/CPT

Prior Authorization

Prior Auth Required

Conditional coverage; review criteria to confirm PA need (medium confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

For suprachoroidal Xipere: documentation that the patient meets the selection criteria specified in CPB 1000 Triamcinolone Acetonide Injectable Suspension (Xipere) (CPB 1000 must be consulted for the specific medical necessity criteria).

For subretinal rtPA: documentation of diagnosis of sub-macular hemorrhage (ICD-10 codes H35.60–H35.63 Retinal hemorrhage/submacular hemorrhage) and clinical rationale for subretinal rtPA injection.

The CPB itself does not list additional explicit documentation elements (e.g., required imaging, prior therapies, or specific timeframes) beyond the requirement to meet the referenced CPB 1000 criteria for Xipere; no other explicit documentation checklist is provided in CPB 0777.

Key Coverage Criteria

Suprachoroidal injection of triamcinolone acetonide injectable suspension (Xipere) for the treatment of macular edema associated with uveitis when criteria are met in CPB 1000 Triamcinolone Acetonide Injectable Suspension (Xipere).
Subretinal injection of recombinant tissue plasminogen activator (rtPA) for the treatment of sub-macular hemorrhage.
CPT/HCPCS/ICD-10 coding references for covered uses (as listed): "67516 Suprachoroidal space injection of pharmacologic agent (separate procedure)" — covered if selection criteria are met (for Xipere);
HCPCS J3299 "Injection, triamcinolone acetonide (Xipere), 1 mg" — covered if selection criteria are met (for Xipere);
ICD-10 H35.81 "Retinal edema" — covered if selection criteria are met (associated with Xipere use);
CPT 0810T "Subretinal injection of a pharmacologic agent, including vitrectomy and 1 or more retinotomies" — covered if selection criteria are met (for subretinal rtPA);

7 Active Policies

HEALTHNET_OR-HNOR-CORTICOSTEROIDS-FOR-OPHTHALMIC-INJECTION-DEXTENZA-ILUVIE-3928170B17, Corticosteroids for ophthalmic injection (Dextenza, Iluvien, Ozurdex, Retisert, Xipere, Yutiq); CP.PHAR.385

BCBSNM-OTH903.035, Triamcinolone acetonide

BCBSOK-OTH903.035, Triamcinolone acetonide

AETNA-CPB-0777, Novel Injection Methods

BCBSIL-OTH903.035, Triamcinolone acetonide

BCBSMT-OTH903.035, Triamcinolone acetonide

BCBSTN-83f43515c6, Triamcinolone Acetonide Injectable Suspension (Xipere)

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J3299, Injection, triamcinolone acetonide (xipere), 1 mg