AVASTIN® (bevacizumab)

No prior authorization required for:

  • Emergency room
  • Inpatient
  • Skilled nursing facility

Injectable auth/billing notes:

Medications billed with miscellaneous codes will be reviewed. Explanatory notes must accompany the claim.

Priority Health Medicare applies CMS local coverage determination criteria when available for Part B drugs.

Code(s): J3590, J9035, J7999, C9257

Benefit: Medical

Notes: No prior authorization required. Avastin also comes in a formulation to treat cancer as a chemotherapeutic agent, use J9035. Do not bill ophthalmic indications with J9035.

Coverage criteriaCovered only when billed with the following ICD-10 diagnoses:

B39.4 Histoplasmosis capsulati, unspecified
B39.5 Histoplasmosis duboisii
B39.9 Histoplasmosis, unspecified
E08.311 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema
E08.321 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema
E08.331 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema
E08.341 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema
E08.351 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema
E08.359 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema
E09.311 Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular edema
E09.321 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E09.331 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
E09.341 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
E09.351 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema
E09.359 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema
E10.311 Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema
E10.321 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E10.331 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
E10.341 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
E13.351 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema
E13.359 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema
E11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema
E11.321 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E11.331 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
E11.341 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
E11.351 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema
E11.359 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema
E13.311 Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema
E13.321 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E13.331 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
E13.341 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
H34.811-H34.819 Central retinal vein occlus
H34.831-H34.839 Tributary (branch) retinal vein occlusion
H34.9 Unspecified retinal vascular occlusion
H35.051-H35.059 Retinal neovascularization unspecified
H35.3210 – H35.3233 Exudative age-related macular degeneration
H35.721-H35.729 Serous detachment of retinal pigment epithelium
H35.81 Retinal edema
H40.50x0-H40.50x4 Glaucoma secondary to other eye disorders, unspecified eye
H40.89 Other specified glaucoma