Does Q5147 require prior authorization?

Yes, Q5147 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for Q5147?

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

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`Q5147`, Injection, aflibercept-ayyh (pavblu), biosimilar, 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).

Claims for aflibercept must include the appropriate HCPCS/J‑codes (J0177, J0178, Q5147, Q5149, Q5150, Q5153, or Q5155) and CPT code 67028 on CMS Form 1500.

When different anti‑VEGF agents are injected into each eye on the same DOS, document the clinical rationale in the medical record and append the correct RT/LT modifier to the corresponding drug line item.

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.
Aflibercept (EYLEA) is FDA‑approved for treatment of neovascular (wet) age‑related macular degeneration (AMD) by intravitreal injection.
Aflibercept (EYLEA) is FDA‑approved for treatment of macular edema following retinal vein occlusion (RVO) by intravitreal injection.
Aflibercept (EYLEA) is FDA‑approved for treatment of diabetic macular edema (DME) by intravitreal injection.
Aflibercept (EYLEA) is FDA‑approved for treatment of diabetic retinopathy (DR) by intravitreal injection.
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.

15 Active Policies

ARKBLUE-NON-BEVACIZUMAB-VASCULAR-EPITHELIAL-GROWTH-FACTO-DADB84DA02, Non-Bevacizumab Vascular Epithelial Growth Factors for Ophthalmic Use (e.g., Beovu, Byooviz, Cimerli, Eylea, Eylea HD, Lucentis, Pavblu, Vabysmo, Enzeevu, Ahzantive, Yesafili, Opuviz)

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

MODA-EYLEA-FE11B961EF, Aflibercept: Ahzantive; Enzeevu; Eydenzelt; Eylea; Eylea HD; Opuviz; Pavblu; Yesafili

BCBSIL-OTH903.027, Aflibercept and Associated Biosimilar(s)

BCBSMT-OTH903.027, Aflibercept and Associated Biosimilar(s)

BCBSNM-OTH903.027, Aflibercept and Associated Biosimilar(s)

BCBSOK-OTH903.027, Aflibercept and Associated Biosimilar(s)

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

BCBSTN-ce0678f4d9, Aflibercept Products (Eylea; EyleaHD, Ahzantive [aflibercept-mrbb], Enzeevu [Aflibercept-abzv], Eydenzelt [Aflibercept-boav], Opuviz [Aflibercept-yszy], Pavblu [Aflibercept-ayyh], and Yesafili [Aflibercept-jbvf])

EVICORE-MEDICAL_DRUG-D37E50177633, Aflibercept (Eylea, Eylea HD, Pavblu) Injection

A53387, Billing and Coding: Aflibercept (EYLEA)

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

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Q5147, Injection, aflibercept-ayyh (pavblu), biosimilar, 1 mg