C9770 — Vitrectomy, mechanical, pars plana approach, with subretinal injection of pharmacologic/biologic agent
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- An area of retina within the posterior pole of greater than 100 µm thickness shown on OCT;or
- The use of voretigene neparvovec-rzyl is consideredmedically necessaryin individuals who meetallof the following criteria:
- A diagnosis of retinal dystrophy due to confirmedRPE65mutation(s) inbothalleles;and
- At least 1 year of age;and
- For each eye indicated for treatment, sufficient viable retinal cells as determined by non-invasive means, such as optical coherence tomography (OCT) and/or ophthalmoscopy as evidenced byoneof the following:An area of retina within the posterior pole of greater than 100 µm thickness shown on OCT;orThree or more disc areas of retina without atrophy or pigmentary degeneration within the posterior pole;orRemaining visual field within 30 degrees of fixation as measured by a III4e isopter or equivale [...]
- Three or more disc areas of retina without atrophy or pigmentary degeneration within the posterior pole;or
1 Active Policy
ANTHEM-MED.00120 — MED.00120 Gene Therapy for Ocular Conditions
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