Does J3396 require prior authorization?

Yes, J3396 requires prior authorization (medium confidence). Conditional coverage; review criteria to confirm PA need.

What is the Medicare reimbursement rate for J3396?

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

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`J3396`, Injection, verteporfin, 0.1 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

No explicit Medicare/coverage-specific documentation requirements are stated in this document.
For IMT: Documentation of evidence of a visually significant cataract (grade 2 or higher).

IMT contraindication documentation: pre-operative documentation of intra-ocular pressure control, endothelial cell density (ECD) counts (minimum baselines: aged 65-84 years ECD ≥ 2,000 cells/mm2; aged 85+ ECD ≥ 1,800 cells/mm2), axial length, anterior chamber depth, absence of active CNV (fluorescein angiography), absence of other disqualifying ocular disease, and no recent intraocular or corneal surgery.

Key Coverage Criteria

Use of any of the following therapies for treatment of neovascular (wet) age-related macular degeneration (ARMD): Aflibercept (Eylea) injection (CPB 0701 - Vascular Endothelial Growth Factor Inhibitors for Ocular Indications).
Use of any of the following therapies for treatment of neovascular (wet) age-related macular degeneration (ARMD): Bevacizumab (Avastin) injection (CPB 0685 - Bevacizumab for Non-Ocular Indications).
Use of any of the following therapies for treatment of neovascular (wet) age-related macular degeneration (ARMD): Pegaptanib sodium (Macugen) injection (CPB 0701 - Vascular Endothelial Growth Factor Inhibitors for Ocular Indications).
Use of any of the following therapies for treatment of neovascular (wet) age-related macular degeneration (ARMD): Photodynamic therapy (PDT) with light-activated verteporfin (CPB 0594 - Visudyne (Verteporfin) Photodynamic Therapy).
Use of any of the following therapies for treatment of neovascular (wet) age-related macular degeneration (ARMD): Ranibizumab (Lucentis) injection (CPB 0701 - Vascular Endothelial Growth Factor Inhibitors for Ocular Indications).
Use of any of the following therapies for treatment of neovascular (wet) age-related macular degeneration (ARMD): Brolucizumab (Beovu) injection (CPB 0701 - Vascular Endothelial Growth Factor Inhibitors for Ocular Indications).

12 Active Policies

HEALTHNET_OR-HNOR-VERTEPORFIN-VISUDYNE-CP-PHAR-187-03D88E4B84, Verteporfin (Visudyne); CP.PHAR.187

IBX-COMMERCIAL-07-13-05M-6D9C1E836F, Photodynamic Therapy (PDT) Using Verteporfin (Visudyne)

IBX-MEDICARE-ADVANTAGE-MA07-003F-2AAF70568F, Photodynamic Therapy Using Verteporfin (Visudyne)

BCBSMT-OTH903.015, Photodynamic Therapy for Choroidal Neovascularization

BCBSNM-OTH903.015, Photodynamic Therapy for Choroidal Neovascularization

BCBSOK-OTH903.015, Photodynamic Therapy for Choroidal Neovascularization

AETNA-CPB-0765, Age-Related Macular Degeneration

AMERIHEALTH-MEDICARE-ADVANTAGE-MA07-003F-929316A0FA, Photodynamic Therapy Using Verteporfin (Visudyne)

BCBSTN-28998aa080, Verteporfin (Visudyne)

AMERIHEALTH-COMMERCIAL-07-13-05M-860CEF01CA, Photodynamic Therapy (PDT) Using Verteporfin (Visudyne)

AETNA-CPB-0594, Verteporfin (Visudyne) Photodynamic Therapy

BCBSIL-OTH903.015, Photodynamic Therapy for Choroidal Neovascularization

`J3396`, Injection, verteporfin, 0.1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

12 Active Policies

Related Codes

Have a follow-up question?

J3396, Injection, verteporfin, 0.1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

12 Active Policies

Related Codes

Have a follow-up question?

`J3396`, Injection, verteporfin, 0.1 mg