J3590, Unclassified biologics
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Documentation Required
- The intravitreal injection procedure must be coded using CPT code 67028 and the appropriate RT, LT, or 50 site modifier must be appended to indicate unilateral or bilateral service.
- Dose and frequency for bevacizumab and biosimilars must follow the FDA label or recognized compendia for off-label uses; compendia cited include AHFS, Clinical Pharmacology, Lexi-Drugs, Micromedex DrugDex, NCCN, FDA, and USP.
- When billing for metastatic (secondary) disease, use the code for the primary malignancy if the primary tumor is still present, and use the appropriate personal history 'Z' code if the primary malignancy is no longer present.
- For Part A and Part B submissions, follow the respective HCPCS coding guidance provided (codes differ by drug form, biosimilar, and effective dates); bill units consistent with the indicated HCPCS code descriptions.
- For management of hypercalcemia of malignancy document ICD-10-CM code E83.52, the related malignancy, and the rationale for denosumab use.
- Medical record must contain documentation that fully supports the medical necessity for administration of the specific denosumab formulation used.
Key Coverage Criteria
- For non-ophthalmologic (systemic) use, bevacizumab must be reported with HCPCS code J9035 (injection, bevacizumab, 10 mg) with units reflecting multiples of 10 mg provided.
- For non-ophthalmologic use, bevacizumab-awwb (MVASI) must be reported with HCPCS code Q5107 (10 mg).
- For non-ophthalmologic use, bevacizumab-bvzr (ZIRABEV) must be reported with HCPCS code Q5118 (10 mg).
- Bevacizumab-maly (ALYMSYS/ALYMSYS1) is reported with HCPCS code C9142 for 10/01/2022–12/31/2022 and with HCPCS code Q5126 effective 01/01/2023 (10 mg).
- Bevacizumab-adcd (Vegzelma) should be reported with HCPCS code Q5129 effective 04/01/2023.
- For the period 09/27/2022 through 03/31/2023 bevacizumab-maly could be reported with miscellaneous code J3590 (per guidance for that timeframe).
20 Active Policies
A52370, Billing and Coding: Bevacizumab and biosimilars
J6
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
J6
A52399, Billing and Coding: Denosumab (Prolia, Xgeva, Jubbonti, Wyost, Ospomyv,Xbryk,Bomyntra, Conexxence, Stoboclo, Osenvelt,Bildyos, Bilprevda)
J6
PALMETTO-JJ-L35026, Rituximab
JJ
NGS-L33394, Drugs and Biologicals, Coverage of, for Label and Off-Label Uses
JK
PALMETTO-JM-L35026, Rituximab
JM
HUMANA-LENMELDY-ATIDARSAGENE-AUTOTEMCEL-SC-MEDICAID, Lenmeldy (atidarsagene autotemcel)
HUMANA-GENE-THERAPY-TREATMENTS-FOR-SICKLE-CELL-DISEASE-MA, Gene Therapy Treatments for Sickle Cell Disease
HUMANA-AMTAGVI-LIFILEUCEL-MA, Amtagvi (lifileucel)
HUMANA-KEBILIDI-ELADOCAGENE-EXUPARVOVEC-TNEQ-MA, Kebilidi (eladocagene exuparvovec-tneq)
HUMANA-AMTAGVI-LIFILEUCEL-SC-MEDICAID, Amtagvi (lifileucel)
ANTHEM-MED.00140, MED.00140 Gene Therapy for Beta Thalassemia
ANTHEM-MED.00135, MED.00135 Gene Therapy for Hemophilia
ANTHEM-MP-E001585, TRANS.00038 Thymus Tissue Transplantation
HUMANA-AMTAGVI-LIFILEUCEL-FL-MEDICAID, Amtagvi (lifileucel)
HUMANA-UMBILICAL-CORD-BLOOD-TRANSPLANTATION-MA, Umbilical Cord Blood Transplantation
ANTHEM-MED.00147, MED.00147 Cellular Therapy Products for Allogeneic Stem Cell Transplantation
ANTHEM-MED.00144, MED.00144 Gene Therapy for Duchenne Muscular Dystrophy
ANTHEM-MED.00146, MED.00146 Gene Therapy for Sickle Cell Disease
HUMANA-LENMELDY-ATIDARSAGENE-AUTOTEMCEL-FL-MEDICAID, Lenmeldy (atidarsagene autotemcel)
Related Codes
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