Does 65855 require prior authorization?

No, 65855 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 65855?

Medicare facility rate: $171.35. Non-facility rate: $245.50. Work RVU: 2.93.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

2.93

Facility

$171.35

Non-Facility

$245.50

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.

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 [...]
Laser trabeculoplasty for treatment of members with refractory primary open-angle glaucoma (POAG) when first-line drugs (e.g., latanoprost or timolol) and second-line drugs (e.g., brimonidine or dorzolamide) have failed to control intra-ocular pressure (IOP).
FDA‑approved aqueous drainage/shunt implants for treatment of members with refractory primary open‑angle glaucoma when first-line and second-line drugs have failed to control IOP. (Examples listed in policy: Ahmed glaucoma implant; Baerveldt seton; Ex‑PRESS mini glaucoma shunt; Glaucoma pressure regulator; Krupin‑Denver valve implant; Molteno implant; Schocket shunt.)
Ab interno Kahook Dual Blade trabeculectomy — described as used for primary congenital glaucoma in case reports (Harvey and Schmitz 2020) and discussed as a minimally invasive technique.

AETNA-CPB-0484 — Glaucoma Surgery

A58392 — Billing and Coding: Dexamethasone Intracanalicular Ophthalmic Insert (Dextenza)

L38792 — Dexamethasone Intracanalicular Ophthalmic Insert (Dextenza)

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

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

Ask Verity about documentation requirements, denial risks, or coverage in your state.