Does E09.3551 require prior authorization?

No, E09.3551 does not require prior authorization (high confidence). Code is covered without prior authorization.

`E09.3551` — Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, right eye

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

The intravitreal injection procedure must be coded using CPT code 67028 and the appropriate RT, LT, or 50 site modifier must be appended to indicate unilateral or bilateral service.
Dose and frequency for bevacizumab and biosimilars must follow the FDA label or recognized compendia for off-label uses; compendia cited include AHFS, Clinical Pharmacology, Lexi-Drugs, Micromedex DrugDex, NCCN, FDA, and USP.
When billing for metastatic (secondary) disease, use the code for the primary malignancy if the primary tumor is still present, and use the appropriate personal history 'Z' code if the primary malignancy is no longer present.
For Part A and Part B submissions, follow the respective HCPCS coding guidance provided (codes differ by drug form, biosimilar, and effective dates); bill units consistent with the indicated HCPCS code descriptions.

For non-ophthalmologic (systemic) use, bevacizumab must be reported with HCPCS code J9035 (injection, bevacizumab, 10 mg) with units reflecting multiples of 10 mg provided.
For non-ophthalmologic use, bevacizumab-awwb (MVASI) must be reported with HCPCS code Q5107 (10 mg).
For non-ophthalmologic use, bevacizumab-bvzr (ZIRABEV) must be reported with HCPCS code Q5118 (10 mg).
Bevacizumab-maly (ALYMSYS/ALYMSYS1) is reported with HCPCS code C9142 for 10/01/2022–12/31/2022 and with HCPCS code Q5126 effective 01/01/2023 (10 mg).
Bevacizumab-adcd (Vegzelma) should be reported with HCPCS code Q5129 effective 04/01/2023.
For the period 09/27/2022 through 03/31/2023 bevacizumab-maly could be reported with miscellaneous code J3590 (per guidance for that timeframe).

A57599 — Billing and Coding: Visual Electrophysiology Testing

J05

A59805 — Billing and Coding: Cataract Surgery

J05

L37015 — Visual Electrophysiology Testing

J05

L35490 — Category III Codes

J05

A56916 — Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

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