J3396, Injection, verteporfin, 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
- No explicit Medicare/coverage-specific documentation requirements are stated in this document.
- For IMT: Documentation of evidence of a visually significant cataract (grade 2 or higher).
- "Visual acuity poorer than 20/160, but not worse than 20/800 in both eyes;"
- "Willingness to participate in a post-operative visual rehabilitation program."
Key Coverage Criteria
- 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).
- Use of any of the following therapies for treatment of neovascular (wet) age-related macular degeneration (ARMD): Photodynamic therapy (PDT) with light-activated verteporfin (CPB 0594 - Visudyne (Verteporfin) Photodynamic Therapy).
- Use of any of the following therapies for treatment of neovascular (wet) age-related macular degeneration (ARMD): Ranibizumab (Lucentis) 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): Brolucizumab (Beovu) injection (CPB 0701 - Vascular Endothelial Growth Factor Inhibitors for Ocular Indications).
6 Active Policies
AETNA-CPB-0765, Age-Related Macular Degeneration
AETNA-CPB-0594, Verteporfin (Visudyne) Photodynamic Therapy
BCBSIL-OTH903.015, Photodynamic Therapy for Choroidal Neovascularization
BCBSMT-OTH903.015, Photodynamic Therapy for Choroidal Neovascularization
BCBSNM-OTH903.015, Photodynamic Therapy for Choroidal Neovascularization
Related Codes
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