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).
2 Active Policies
AETNA-CPB-0594 — Verteporfin (Visudyne) Photodynamic Therapy
AETNA-CPB-0765 — Age-Related Macular Degeneration
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.