J3403, Revakinagene taroretcel-lwey, per implant
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
- Authorization will be issued for no more than one treatment per eye per lifetime and for no longer than 60 days from approval
Key Coverage Criteria
- Encelto is proven and medically necessary for the treatment of adults with idiopathic MacTel who meet all of the following for initial therapy: patient age >= 18; diagnosis confirmed in at least one eye; monitored for retinal tears/detachment signs; prescribed by an ophthalmologist; dosing per FDA labeling; authorization for no more than one treatment per eye per lifetime and not longer than 60 days from approval.
- Indication: Encelto is medically necessary for adults (age >= 18) with idiopathic MacTel type 2, requiring: (1) diagnosis confirmed in at least one eye, (2) ophthalmologist prescription, (3) dosing per FDA-approved labeling, (4) authorization for max 1 treatment per eye per lifetime and for up to 60 days from approval, and (5) monitoring for retinal tears/detachment.
- Encelto is proven and medically necessary for the treatment of adults with idiopathic macular telangiectasia type 2 (MacTel) who meet all of the following: For initial therapy, all of the following: o Patient is at least 18 years of age; and o Submission of medical records (e.g., chart notes) confirming diagnosis of non-proliferative macular telangiectasia type 2 (MacTel) in at least one eye; and o Patient will be monitored for signs and symptoms of retinal tears and/or retinal detachment (e.g., [...]
3 Active Policies
UHC-POL-encelto, Encelto (Revakinagene Taroretcel-Lwey)
UMR-POL-UMR-encelto, Encelto (Revakinagene Taroretcel-Lwey)
SUREST-POL-SUREST-encelto, Encelto (Revakinagene Taroretcel-Lwey)
Related Codes
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