0465T — Injection of medication into space above choroid membrane of eye
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Evidence that the therapy is effective for the member's specific diagnosis or procedure (clinical literature or guideline citation).
- For drug therapy, documentation of proposed dose, frequency, and duration and citation to at least one authoritative source supporting those parameters (e.g., FDA labeling, MCG, DrugDex, NCCN Guidelines/Compendia).
- Supporting references from nationally recognized authoritative sources or major drug compendia (examples: MCG care guidelines, DrugDex, NCCN).
- Citation or evidence from one or more standard medical reference compendia adopted by HHS supporting the indication, OR
Key Coverage Criteria
- Requested therapies that are proven effective for the relevant diagnosis or procedure.
- Drug therapies when proposed dose, frequency, and duration are consistent with recommendations from at least one authoritative source.
- Coverage for any FDA‑approved drug when prescribed for a use recognized as safe and effective in one or more standard medical reference compendia adopted by the U.S. Department of Health and Human Services.
- Coverage for any FDA‑approved drug when prescribed for an off‑label use supported by medical literature consisting of two articles from major peer‑reviewed professional medical journals that confirm safety and efficacy for the proposed use.
- Suprachoroidal injection of triamcinolone acetonide (Xipere) for treatment of macular edema associated with uveitis in individuals aged ≥18 years, with non-infectious uveitis, when the prescriber will not exceed the FDA‑labeled dose of 4 mg per affected eye.
- Use for FDA‑approved indication(s) for suprachoroidal triamcinolone (Xipere®) only
1 Active Policy
OTH903.035 — Triamcinolone acetonide
Related Codes
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