Does E11.311 require prior authorization?

No, E11.311 does not require prior authorization (high confidence). Code is covered without prior authorization.

Verity

`E11.311` — Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema

ICD-10-CM

Prior Authorization

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Documentation Required

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.

Key Coverage Criteria

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).

20 Active Policies

A56232 — Billing and Coding: Foot Care

J05

L34760 — Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

J05

L37015 — Visual Electrophysiology Testing

J05

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

J05

A59805

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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).

— Billing and Coding: Cataract Surgery

A57599 — Billing and Coding: Visual Electrophysiology Testing

J05

L38686 — Implantable Continuous Glucose Monitors (I-CGM)

J05

L39905 — Cataract Surgery

J05

L35490 — Category III Codes

J05

A58213 — Billing and Coding: Implantable Continuous Glucose Monitors (I-CGM)

J05

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

A52370 — Billing and Coding: Bevacizumab and biosimilars

J06

A57060 — Billing and Coding: Visual Electrophysiology Testing

J06

A59901 — Billing and Coding: Bevacizumab and biosimilars

J06

A56726 — Billing and Coding: Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)

J06

A56551 — Billing and Coding: Visual Fields Testing

J06

L38623 — Implantable Continuous Glucose Monitors (I-CGM)

J06

A58116 — Billing and Coding: Implantable Continuous Glucose Monitors (I-CGM)

J06

A56550 — Billing and Coding: Panretinal (Scatter) Laser Photocoagulation

J06

A56537 — Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

J06

E11.311 — Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema