Does J3490 require prior authorization?

No, J3490 does not require prior authorization (low confidence). No active coverage policies found for this code.

What is the Medicare reimbursement rate for J3490?

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

Verity

`J3490`, Unclassified drugs

HCPCS/CPT

Prior Authorization

No Prior Auth Required

No active coverage policies found for this code (low confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

Medical record must document indication, route (intravitreal), dose and dosing frequency consistent with the FDA label or include literature support when dosing/frequency deviates from the FDA label.
The intravitreal administration must be billed with CPT 67028 on the same claim as the drug (or CPT 67027 for SUSVIMO) and must include the appropriate site modifier (RT, LT, or 50).
For Part A and Part B MAC claims, report the drug using the specified HCPCS/J-codes or Q-codes as listed by product (e.g., ranibizumab J2778/J2779 or Q5124/Q5128, aflibercept J0178 or J0177/Q-codes for biosimilars, brolucizumab-dbll J0179, faricimab-svoa J2777).
Every Part A claim for NOC/unlisted drug, biologic, and radiopharmaceutical codes must include the appropriate NOC code and the appropriate diagnosis.
Every claim must include the appropriate revenue codes for the drug and for IV infusion when applicable.
Every claim must indicate the drug name, the National Drug Code (NDC) number, and the total dosage administered.

Key Coverage Criteria

Intravitreal administration of ranibizumab (including ranibizumab-nuna and ranibizumab-eqrn), aflibercept (including aflibercept HD and biosimilars PAVBLU™, AHZANTIVE®, ENZEEVU™, OPUVIZ™, YESAFILI™), brolucizumab-dbll, and faricimab-svoa is covered when used consistent with the FDA-approved package insert or supported compendia/literature for off-label uses.
For claims using not otherwise classified (NOC)/unlisted HCPCS codes J3490, J3590, J9999, A4641, or A9699 with limited or specific indications, submit required documentation in the claim remarks field (Field Locator 80 on the UB-04) or the equivalent 5010 electronic claim field so Palmetto GBA can ascertain FDA labeling indications have been met.
For oncology drugs or oncology radiopharmaceuticals submitted with NOC codes prior to assignment of a unique HCPCS code, include the diagnosis code that corresponds to the specific FDA label indication or, if no adequate diagnosis code exists, include a specific narrative description of the indication (e.g., 'squamous cell carcinoma').
Adult onset (16 years of age or older) phenotype presenting with dementia
Metachromatic leukodystrophy (MLD) — general description as the disease addressed by the policy.
Symptoms of MLD including behavioral changes, cognitive regression, gastrointestinal issues, progressive motor impairment and seizures.

20 Active Policies

CGS-L33960, Cardiovascular Nuclear Medicine

J15

CGS-L34338, Transthoracic Echocardiography (TTE)

J15

A52451, Billing and Coding: Ranibizumab and biosimilars, Aflibercept, Aflibercept HD, Brolucizumab-dbll, Faricimab-svoa, PAVBLUaflibercept-ayyh, AHZANTIVEaflibercept-abzv. ENZEEVUaflibercept-mrbb, OPUVIZaflibercept-yszy and YESAFILI aflibercept-jbvf

NORIDIAN-L34324, Cardiovascular Stress Testing, Including Exercise and/or Pharmacological Stress and Stress Echocardiography

NORIDIAN-L36538, Treatment of Males with Low Testosterone

PALMETTO-JJ-L39086, Treatment of Males with Low Testosterone

NGS-L33394, Drugs and Biologicals, Coverage of, for Label and Off-Label Uses

PALMETTO-JM-L39086, Treatment of Males with Low Testosterone

HUMANA-AMTAGVI-LIFILEUCEL-SC-MEDICAID, Amtagvi (lifileucel)

ANTHEM-SURG.00132, SURG.00132 Drug-Eluting Devices for Maintaining Sinus Ostial Patency

HUMANA-KEBILIDI-ELADOCAGENE-EXUPARVOVEC-TNEQ-MA, Kebilidi (eladocagene exuparvovec-tneq)

ANTHEM-MED.00120, MED.00120 Gene Therapy for Ocular Conditions

ANTHEM-MED.00144, MED.00144 Gene Therapy for Duchenne Muscular Dystrophy

ANTHEM-MED.00147, MED.00147 Cellular Therapy Products for Allogeneic Stem Cell Transplantation

HUMANA-LENMELDY-ATIDARSAGENE-AUTOTEMCEL-SC-MEDICAID, Lenmeldy (atidarsagene autotemcel)

ANTHEM-SURG.00160, SURG.00160 Implanted Port Delivery Systems to Treat Ocular Disease

A54880, Billing and Coding: Additional Claim Documentation Requirements for Not Otherwise Classified (NOC) Drugs and Biological Products with Specific FDA Label Indications

ANTHEM-MED.00129, MED.00129 Gene Therapy for Spinal Muscular Atrophy

HUMANA-AMTAGVI-LIFILEUCEL-FL-MEDICAID, Amtagvi (lifileucel)

ANTHEM-MED.00132, MED.00132 Autologous Adipose-derived Regenerative Cell Therapy

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J3490, Unclassified drugs