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
- Documentation of dosing consistent with the United States Food and Drug Administration approved labeling.
- Submission of medical records (e.g., chart notes) confirming diagnosis of non-proliferative macular telangiectasia type 2 (MacTel) in at least one eye.
- Documentation that the patient is at least 18 years of age.
- Documentation that the patient will be monitored for signs and symptoms of retinal tears and/or retinal detachment (e.g., notes documenting monitoring plan or counseling about acute onset of flashing lights, floaters, and/or loss of visual acuity).
Key Coverage Criteria
- For initial therapy, all of the following: Patient is at least 18 years of age.
- Encelto is proven and medically necessary for the treatment of adults with idiopathic macular telangiectasia type 2 (MacTel).
- For initial therapy, all of the following: Submission of medical records (e.g., chart notes) confirming diagnosis of non-proliferative macular telangiectasia type 2 (MacTel) in at least one eye.
- For initial therapy, all of the following: Patient will be monitored for signs and symptoms of retinal tears and/or retinal detachment (e.g., acute onset of flashing lights, floaters, and/or loss of visual acuity).
- For initial therapy, all of the following: Encelto is prescribed by an ophthalmologist.
- For initial therapy, all of the following: Dosing is in accordance with the United States Food and Drug Administration approved labeling.
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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