Does J3398 require prior authorization?

No, J3398 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for J3398?

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

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Claims must include a valid ICD-10-CM diagnosis code that best describes the patient's condition; claims lacking a valid diagnosis code will be returned as incomplete under Section 1833(e).
For services requiring a referring/ordering physician, the referring/ordering physician's name and NPI must be reported on the claim.
Report diagnostic test results when known; if results are not available, report the symptoms that prompted the test.
On claims for Luxturna® the HCPCS code (C9032 for 07/01/2018–12/31/2018; J3398 for dates of service on/after 01/01/2019) must be reported with the appropriate eye modifier (-RT or -LT) and the number of HCPCS units administered must be submitted.

Voretigene neparvovec-rzyl (Luxturna®) is covered for treatment of vision loss due to heritable retinal dystrophies in patients with confirmed biallelic RPE65 mutation-associated retinal dystrophy.
Coverage applies when the patient has sufficient viable photoreceptors such that a single subretinal administration is expected to clinically improve functional vision.
Indications include patients with autosomal recessive retinitis pigmentosa (RP) or Leber congenital amaurosis (LCA) when caused by biallelic RPE65 mutations.
Treatment of inherited retinal dystrophies (IRD) caused by mutations in the RPE65 gene in patients who meet all listed criteria.
Patient is greater than 12 months of age.
Diagnosis of a confirmed biallelic RPE65 mutation-associated retinal dystrophy (examples given: Leber's congenital amaurosis (LCA), retinitis pigmentosa (RP), early onset severe retinal dystrophy (EOSRD), etc.).

PALMETTO-JJ-L37863, Voretigene Neparvovecrzyl (Luxturna®)

PALMETTO-JM-L37863, Voretigene Neparvovecrzyl (Luxturna®)

UHC-POL-luxturna-voretigene-neparvovec-rzyl, Luxturna (Voretigene Neparvovec-Rzyl)

BCBSIL-RX501.098, Gene Therapy for Inherited Retinal Dystrophy

BCBSMT-RX501.098

Ask Verity about documentation requirements, denial risks, or coverage in your state.