Does J2778 require prior authorization?

No, J2778 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for J2778?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

Verity

`J2778`, Injection, ranibizumab, 0.1 mg

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

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).
For Part A and Part B MAC claims, report the drug using the specified HCPCS/J-codes or Q-codes as listed by product (e.g., ranibizumab J2778/J2779 or Q5124/Q5128, aflibercept J0178 or J0177/Q-codes for biosimilars, brolucizumab-dbll J0179, faricimab-svoa J2777).
No explicit Medicare/coverage-specific documentation requirements are stated in this document.

Key Coverage Criteria

Intravitreal administration of ranibizumab (including ranibizumab-nuna and ranibizumab-eqrn), aflibercept (including aflibercept HD and biosimilars PAVBLU™, AHZANTIVE®, ENZEEVU™, OPUVIZ™, YESAFILI™), brolucizumab-dbll, and faricimab-svoa is covered when used consistent with the FDA-approved package insert or supported compendia/literature for off-label uses.
Initial therapy for ophthalmologic VEGF/Ang-2 inhibitors requires (1) diagnosis, (2) intravitreal VEGF or dual VEGF/Ang-2 inhibitor administration limited to 12 doses per year per eye, and (3) authorization for a maximum of 12 months.
Eylea (aflibercept) is proven and medically necessary for diabetic macular edema, diabetic retinopathy, macular edema following retinal vein occlusion, neovascular age-related macular degeneration, and retinopathy of prematurity.
Use of any of the following therapies for treatment of neovascular (wet) age-related macular degeneration (ARMD): Aflibercept (Eylea) injection (CPB 0701 - Vascular Endothelial Growth Factor Inhibitors for Ocular Indications).
Use of any of the following therapies for treatment of neovascular (wet) age-related macular degeneration (ARMD): Bevacizumab (Avastin) injection (CPB 0685 - Bevacizumab for Non-Ocular Indications).
Use of any of the following therapies for treatment of neovascular (wet) age-related macular degeneration (ARMD): Pegaptanib sodium (Macugen) injection (CPB 0701 - Vascular Endothelial Growth Factor Inhibitors for Ocular Indications).

15 Active Policies

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

NGS-L33394, Drugs and Biologicals, Coverage of, for Label and Off-Label Uses

AETNA-CPB-0484, Glaucoma Surgery

BCBSIL-OTH903.015, Photodynamic Therapy for Choroidal Neovascularization

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J2778, Injection, ranibizumab, 0.1 mg