Does 67516 require prior authorization?

No, 67516 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 67516?

Medicare facility rate: $79.83. Non-facility rate: $121.25. Work RVU: 1.49.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

1.49

Facility

$79.83

Non-Facility

$121.25

For suprachoroidal Xipere: documentation that the patient meets the selection criteria specified in CPB 1000 Triamcinolone Acetonide Injectable Suspension (Xipere) (CPB 1000 must be consulted for the specific medical necessity criteria).
Diagnosis documentation supporting macular edema associated with uveitis (ICD-10 code listed: H35.81 Retinal edema) when billing the covered codes for Xipere.
For subretinal rtPA: documentation of diagnosis of sub-macular hemorrhage (ICD-10 codes H35.60–H35.63 Retinal hemorrhage/submacular hemorrhage) and clinical rationale for subretinal rtPA injection.
The CPB itself does not list additional explicit documentation elements (e.g., required imaging, prior therapies, or specific timeframes) beyond the requirement to meet the referenced CPB 1000 criteria for Xipere; no other explicit documentation checklist is provided in CPB 0777.

Suprachoroidal injection of triamcinolone acetonide injectable suspension (Xipere) for the treatment of macular edema associated with uveitis when criteria are met in CPB 1000 Triamcinolone Acetonide Injectable Suspension (Xipere).
Subretinal injection of recombinant tissue plasminogen activator (rtPA) for the treatment of sub-macular hemorrhage.
CPT/HCPCS/ICD-10 coding references for covered uses (as listed): "67516 Suprachoroidal space injection of pharmacologic agent (separate procedure)" — covered if selection criteria are met (for Xipere);
HCPCS J3299 "Injection, triamcinolone acetonide (Xipere), 1 mg" — covered if selection criteria are met (for Xipere);
ICD-10 H35.81 "Retinal edema" — covered if selection criteria are met (associated with Xipere use);
CPT 0810T "Subretinal injection of a pharmacologic agent, including vitrectomy and 1 or more retinotomies" — covered if selection criteria are met (for subretinal rtPA);

AETNA-CPB-0777 — Novel Injection Methods

BCBSIL-OTH903.035 — Triamcinolone acetonide

BCBSMT-OTH903.035 — Triamcinolone acetonide

BCBSNM-OTH903.035 — Triamcinolone acetonide

BCBSOK-OTH903.035 — Triamcinolone acetonide

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