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.
- 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).
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
J06
A59901 — Billing and Coding: Bevacizumab and biosimilars
J06
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
J06
L33394 — Drugs and Biologicals, Coverage of, for Label and Off-Label Uses
J06
PALMETTO-N/A — N/A
JJ Part B
PALMETTO-L35026 — Rituximab
JJ Part B
N/A — N/A
JJ Part B
NGS-L33394 — Drugs and Biologicals, Coverage of, for Label and Off-Label Uses
JK MAC Part B
HUMANA-AMTAGVI-LIFILEUCEL-MA — Amtagvi (lifileucel) - Medicare Advantage
HUMANA-ZEVASKYN-PRADEMAGENE-ZAMIKERACEL-SC-MEDICAID — Zevaskyn (prademagene zamikeracel) - MEDICAID - SOUTH CAROLINA
HUMANA-RETHYMIC-ALLOGENEIC-PROCESSED-THYMUS-TISSUE-AGDC-SC-MEDICAID — Rethymic (allogeneic processed thymus tissue-agdc) - MEDICAID - SOUTH CAROLINA
HUMANA-LENMELDY-ATIDARSAGENE-AUTOTEMCEL-FL-MEDICAID — Lenmeldy (atidarsagene autotemcel) - MEDICAID - FLORIDA
HUMANA-AMTAGVI-LIFILEUCEL-FL-MEDICAID — Amtagvi (lifileucel) - MEDICAID - FLORIDA
HUMANA-KEBILIDI-ELADOCAGENE-EXUPARVOVEC-TNEQ-MA — Kebilidi (eladocagene exuparvovec-tneq) - Medicare Advantage
CIGNA-0511 — Injectable Fillers for Head and Neck Conditions - (0511)
HUMANA-LENMELDY-ATIDARSAGENE-AUTOTEMCEL-SC-MEDICAID — Lenmeldy (atidarsagene autotemcel) - MEDICAID - SOUTH CAROLINA
ANTHEM-MED.00135 — MED.00135 Gene Therapy for Hemophilia
HUMANA-GENE-THERAPY-TREATMENTS-FOR-SICKLE-CELL-DISEASE-MA — Gene Therapy Treatments for Sickle Cell Disease - Medicare Advantage
HUMANA-ZEVASKYN-PRADEMAGENE-ZAMIKERACEL-MA — Zevaskyn (prademagene zamikeracel) - Medicare Advantage
ANTHEM-MED.00140 — MED.00140 Gene Therapy for Beta Thalassemia
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.