Does 65820 require prior authorization?

No, 65820 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 65820?

Medicare facility rate: $723.46. Non-facility rate: $723.46. Work RVU: 8.69.

Verity

`65820`

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

8.69

Facility

$723.46

Non-Facility

$723.46

Documentation Required

Billing, coding, and other guidelines for Dexamethasone Intracanalicular Ophthalmic Insert (Dextenza®) must follow and complement Local Coverage Determination L38792.
Document the qualifying ophthalmic surgery and the post-operative diagnosis of ocular inflammation.
Document the qualifying ophthalmic surgery and the post-operative diagnosis of ocular pain.
Document absence of active corneal, conjunctival, or canalicular infections (screening/exam findings) prior to insert placement.

Key Coverage Criteria

Dextenza is covered for treatment of ocular inflammation following ophthalmic surgery.
Dextenza is covered for treatment of ocular pain following ophthalmic surgery.
Goniotomy or trabeculotomy for pediatric glaucoma (age 18 years or less) Goniotomy, trabeculotomy, canaloplasty (ab interno), or combined canaloplasty (ab interno) and trabeculotomy (e.g., OMNI® Surgical System, Streamline Surgical System) for adults (age 19 years or more) when used in combination with cataract surgery for treating mild to moderate open-angle glaucoma (OAG) and cataract in adults currently being treated with ocular hypotensive medication iStent®, iStent inject®, or Hydrus® Micro [...]
Primary congenital glaucoma (PCG) — viscocanalostomy/combined viscocanalostomy and trabeculotomy were studied in pediatric PCG (Qian 2017; Cochrane review includes trials comparing viscocanalostomy).
Use as a MIGS (minimally invasive glaucoma surgery) option for earlier-stage glaucoma where bleb-related complications are a concern — e.g., statement: "Canaloplasty will likely be used most often in earlier stages of glaucoma...may also be indicated in patients who may not need IOP-lowering to the degree that is achievable with trabeculectomy."
Procedures / devices discussed (clinical contexts in which they were studied): viscocanalostomy, phacoviscocanalostomy, canaloplasty (including iTrack/Glaucolight microcatheter approaches), canaloplasty with Stegmann Canal Expander, ab interno canaloplasty (ABiC), OMNI Surgical System (360° canaloplasty + 180° trabeculotomy), Visco360, iStent, Trabectome, GATT combined with ABiC.

9 Active Policies

PALMETTO-L38792 — Dexamethasone Intracanalicular Ophthalmic Insert (Dextenza®)

JJ Part B

PALMETTO-L37531 — Micro-Invasive Glaucoma Surgery (MIGS)

JJ Part B

L38792 — Dexamethasone Intracanalicular Ophthalmic Insert (Dextenza)

UHC-POL-glaucoma-surgical-treatments — Glaucoma Surgical Treatments

AETNA-CPB-0435

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65820