J9035, Injection, bevacizumab, 10 mg
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires 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.
- No explicit Medicare/coverage-specific documentation requirements are stated in this document.
- For IMT: Documentation of evidence of a visually significant cataract (grade 2 or higher).
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
NGS-L33394, Drugs and Biologicals, Coverage of, for Label and Off-Label Uses
JK
UHC-POL-ophthalmologic-vegf-inhibitors, Ophthalmologic Vascular Endothelial Growth Factor (VEGF) Inhibitors
AETNA-CPB-0765, Age-Related Macular Degeneration
AETNA-CPB-0663, Cerebral Perfusion Studies
AETNA-CPB-0484, Glaucoma Surgery
AETNA-CPB-0389, Hypertrophic Scars and Keloids
BCBSIL-RX502.061, Oncology Medications
BCBSIL-OTH903.015, Photodynamic Therapy for Choroidal Neovascularization
BCBSMT-RX502.061, Oncology Medications
BCBSMT-OTH903.015, Photodynamic Therapy for Choroidal Neovascularization
BCBSNM-RX502.061, Oncology Medications
BCBSNM-OTH903.015, Photodynamic Therapy for Choroidal Neovascularization
BCBSOK-RX502.061, Oncology Medications
BCBSOK-OTH903.015, Photodynamic Therapy for Choroidal Neovascularization
UMR-POL-UMR-oncology-medication-clinical-coverage-policy, Oncology Medication Clinical Coverage
UMR-POL-UMR-ophthalmologic-vegf-inhibitors, Ophthalmologic Vascular Endothelial Growth Factor (VEGF) Inhibitors
SUREST-POL-SUREST-oncology-medication-clinical-coverage-policy, Oncology Medication Clinical Coverage
SUREST-POL-SUREST-ophthalmologic-vegf-inhibitors, Ophthalmologic Vascular Endothelial Growth Factor (VEGF) Inhibitors
EVICORE-HPLAN-CIGNA-91DEEEDD92F8, Cigna MedOnc Master Drug List
Related Codes
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