67027
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
11.33
Facility
$715.11
Non-Facility
$715.11
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 must report the appropriate laterality modifier (-RT or -LT) on each claim line for unilateral procedures or the appropriate bilateral modifier for bilateral procedures; documentation on the claim itself (modifier placement) is required to avoid denial.
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.
- Claims for CPT/HCPCS codes describing services on anatomic structures that can be distinguished as left or right must include the appropriate laterality modifier (-RT or -LT) on each claim line for unilateral procedures.
- Bilateral procedures must be indicated by the appropriate bilateral modifier (use the payer- or code-specific bilateral modifier rather than -RT/-LT).
- CPT codes whose descriptions explicitly state 'unilateral or bilateral' do not require additional laterality modifiers.
- NGS covers leuprolide acetate (LHRH analog) as palliative treatment of advanced breast carcinoma in premenopausal and perimenopausal women.
- A drug use is covered if it is an FDA-approved labeled indication or is a medically accepted off-label indication supported by one of the accepted compendia at the specified levels (AHFS-DI supportive; NCCN Category 1 or 2A; Micromedex DrugDex Class I/IIa/IIb or Clinical Pharmacology supportive; Lexi-Drugs Evidence Level A) or by articles or LCDs published by National Government Services (NGS).
7 Active Policies
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
J06
L33394 — Drugs and Biologicals, Coverage of, for Label and Off-Label Uses
J06
A58392 — Billing and Coding: Dexamethasone Intracanalicular Ophthalmic Insert (Dextenza)
AETNA-CPB-0719 — Fluocinolone Acetonide Intra-vitreal Implant (Retisert, Yutiq and Iluvien)
Related Codes
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