J2781 — Injection, pegcetacoplan, intravitreal, 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
- Clinical documentation confirming diagnosis of geographic atrophy (GA) secondary to age-related macular degeneration (AMD).
- Results of geographic atrophy sensitive tests confirming GA (examples given: optical coherence tomography [OCT], fundus autofluorescence [FAF] imaging).
- Documentation that macular atrophy is not due to other causes (e.g., documentation excluding Stargardt disease, cone rod dystrophy, toxic maculopathies).
- Prescription or consultation note from an ophthalmologist experienced in treating retinal diseases (prescriber qualification/consultation evidence).
Key Coverage Criteria
- Treatment of geographic atrophy (GA) secondary to age-related macular degeneration (AMD) (adult patients), using avacincaptad pegol (Syfovre) or pegcetacoplan (Izervay) when all coverage criteria are met.
- Diagnosis of geographic atrophy (GA) secondary to age-related macular degeneration (AMD) confirmed by geographic atrophy sensitive tests (e.g., optical coherence tomography [OCT], fundus autofluorescence [FAF] imaging).
- Use when prescribed by or in consultation with an ophthalmologist experienced in treatment of retinal diseases.
- Use consistent with United States Food and Drug Administration approved labeling for the product (dosing and administration).
- Initial therapy authorization may be granted for up to 12 months when criteria are met.
- Continuation (maintenance/long-term) therapy when physician attests patient would benefit from continued administration and other continuation criteria are met (authorization up to 12 months).
3 Active Policies
UHC-POL-ophthalmologic-complement-inhibitors — Ophthalmologic Complement Inhibitors
UMR-POL-UMR-ophthalmologic-complement-inhibitors — Ophthalmologic Complement Inhibitors
SUREST-POL-SUREST-ophthalmologic-complement-inhibitors — Ophthalmologic Complement Inhibitors
Related Codes
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