C9759, Transcatheter intraoperative blood vessel microinfusion(s) (e.g., intraluminal,
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- 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.
Key Coverage Criteria
- 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);
1 Active Policy
AETNA-CPB-0777, Novel Injection Methods
Related Codes
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