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ICD-10-CM T66.XXXS, Radiation sickness, unspecified, sequela | No Prior Auth

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`T66.XXXS`, Radiation sickness, unspecified, sequela

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

The intravitreal injection procedure must be coded using CPT code 67028 and the appropriate RT, LT, or 50 site modifier must be appended to indicate unilateral or bilateral service.
Dose and frequency for bevacizumab and biosimilars must follow the FDA label or recognized compendia for off-label uses; compendia cited include AHFS, Clinical Pharmacology, Lexi-Drugs, Micromedex DrugDex, NCCN, FDA, and USP.
When billing for metastatic (secondary) disease, use the code for the primary malignancy if the primary tumor is still present, and use the appropriate personal history 'Z' code if the primary malignancy is no longer present.
For Part A and Part B submissions, follow the respective HCPCS coding guidance provided (codes differ by drug form, biosimilar, and effective dates); bill units consistent with the indicated HCPCS code descriptions.

Key Coverage Criteria

For non-ophthalmologic (systemic) use, bevacizumab must be reported with HCPCS code J9035 (injection, bevacizumab, 10 mg) with units reflecting multiples of 10 mg provided.
For non-ophthalmologic use, bevacizumab-awwb (MVASI) must be reported with HCPCS code Q5107 (10 mg).
For non-ophthalmologic use, bevacizumab-bvzr (ZIRABEV) must be reported with HCPCS code Q5118 (10 mg).
Bevacizumab-maly (ALYMSYS/ALYMSYS1) is reported with HCPCS code C9142 for 10/01/2022–12/31/2022 and with HCPCS code Q5126 effective 01/01/2023 (10 mg).
Bevacizumab-adcd (Vegzelma) should be reported with HCPCS code Q5129 effective 04/01/2023.
For the period 09/27/2022 through 03/31/2023 bevacizumab-maly could be reported with miscellaneous code J3590 (per guidance for that timeframe).

20 Active Policies

CGS-J15-L36658, Proton Beam Therapy

J15

CGS-J18-L36658, Proton Beam Therapy

J18

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

J6

NGS-J6-L33577, Transthoracic Echocardiography (TTE)

J6

NGS-J6-L35075

Related Codes

T66.XXXA(20 policies)T66.XXXD(19 policies)C22.0(14 policies)C22.8(14 policies)C22.3(14 policies)C25.1(13 policies)C25.0(13 policies)C25.2(13 policies)

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All documentation must be maintained in the patient medical record, be legible, include patient identification (complete name, dates of service), and be available to the contractor upon request.

Medical record must identify the physician or non-physician practitioner responsible for and providing the patient's care.

, Proton Beam Therapy

J6

NGS-J6-L35076, Stereotactic Radiation Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT)

J6

A56827, Billing and Coding: Proton Beam Therapy

J6

A52370, Billing and Coding: Bevacizumab and biosimilars

J6

A56781, Billing and Coding: Transthoracic Echocardiography (TTE)

J6

A56874, Billing and Coding: Stereotactic Radiation Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT)

J6

A57063, Billing and Coding: Diagnostic and Therapeutic Esophagogastroduodenoscopy

J9

FIRST_COAST-L33583, Diagnostic and Therapeutic Esophagogastroduodenoscopy

J9

NGS-JK-L33577, Transthoracic Echocardiography (TTE)

JK

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

JK

NGS-JK-L35075, Proton Beam Therapy

JK

NGS-JK-L35076, Stereotactic Radiation Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT)

JK

ANTHEM-CG-MED-73, Hyperbaric Oxygen Therapy (Systemic/Topical)

A56625, Billing and Coding: Echocardiography

A55315, Billing and Coding: Proton Beam Therapy

A56612, Billing and Coding: CT of the Head