Q5128, Injection, ranibizumab-eqrn (cimerli), biosimilar, 0.1 mg
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
- 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).
- Initial therapy requires diagnosis, maximum 12 intravitreal VEGF/dual VEGF-Ang-2 inhibitor doses per year per eye, and authorization for up to 12 months.
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.
- Initial therapy for ophthalmologic VEGF/Ang-2 inhibitors requires (1) diagnosis, (2) intravitreal VEGF or dual VEGF/Ang-2 inhibitor administration limited to 12 doses per year per eye, and (3) authorization for a maximum of 12 months.
- Eylea (aflibercept) is proven and medically necessary for diabetic macular edema, diabetic retinopathy, macular edema following retinal vein occlusion, neovascular age-related macular degeneration, and retinopathy of prematurity.
- Intravitreal ranibizumab (Lucentis/Byooviz/Cimerli) may be considered medically necessary for diabetic macular edema (DME).
- Intravitreal ranibizumab (Lucentis/Byooviz/Cimerli) may be considered medically necessary for diabetic retinopathy (DR).
- Intravitreal ranibizumab (Lucentis/Byooviz/Cimerli) may be considered medically necessary for macular edema following central retinal vein occlusion (CRVO).
9 Active Policies
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
NGS-L33394, Drugs and Biologicals, Coverage of, for Label and Off-Label Uses
JK
BCBSIL-OTH903.041, Ranibizumab Injections, Implants and Biosimilars
BCBSMT-OTH903.041, Ranibizumab Injections, Implants and Biosimilars
Related Codes
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