Lucentis® (ranibizumab)

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): J2778

Benefit: Medical

Notes:

  • Treatment of AMD and RVO
  • Prior use of Avastin® (bevacizumab)
  • Covered for Medicare only when billed with the following ICD-10 diagnoses:

E08.311, Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema
E08.3211–E08.3213, Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema
E08.3311–E08.3313, Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema
E08.3411– E08.3413, Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema
E08.3511- E08.3513, Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema
E09.311, Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular edema
E09.3211-E09.3213, Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E09.3311-E09.3313, Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
E09.3411- E09.3413, Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
E09.3511- E09.3513, Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema
E10.311, Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema
E10.3211- E10.3213, Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E10.3311- E10.3313, Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
E10.3411- E10.3413, Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
E10.3511-E10.3513, Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema
E11.3411- E11.3413, >Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
E11.3511 E11.3513, Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema
E13.311, Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema
E13.3211- E13.3213, Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E11.311, Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema
E11.3211- E11.3213, Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E11.3311- E11.3313, Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
E13.3311- E13.3313, Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
E13.3411-E13.3413, Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
E13.3511- E13.3513, Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema
H34.8110-H34.8132, Central retinal vein occlusion
H34.8120 – H34.8122, Central retinal vein occlusion
H34.8310-H34.8332, Tributary (branch) retinal vein occlusion
H35.051-H35.053, Retinal neovascularization, unspecified
H35.3210-H35.323, Exudative age-related macular degeneration
H35.81, Retinal edema