Medicare Advantage Medical Policy Bulletin
Section: Injections
Number: I-100
Topic: Avastin Coverage for Intraocular Use
Effective Date: October 11, 2010
Issued Date: October 11, 2010

General Policy

This policy addresses the use of bevacizumab (Avastin) coverage for intraocular use only.

Indications and Limitations of Coverage

HCPCS code J9035 describes bevacizumab use for chemotherapy, and must not be submitted for intraocular use. Since HCPCS code J9035 - injection, bevacizumab, 10 mg, describes the chemotherapeutic dose and the intraocular use requires compounding to constitute the 1.25 mg dose, please use HCPCS code J3590, unclassified biologics for these services.

Bevacizumab for intraocular use will be denied as not medically necessary when reported with a diagnosis code not listed in the diagnosis section of the policy. A provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

Procedure Codes

J3590     

Coding Guidelines

Publications

Provider News

06/2010, Avastin for intraocular use

References

Joint Signature Memorandum (JSM) 10049, November 16, 2009.

www.cms.gov
www.medicare.gov

Attachments

Procedure Code Attachments

Diagnosis Codes

362.01-362.07362.15362.16362.29
362.30362.35362.36362.52
362.53362.83362.84364.42
365.63365.89  

Glossary




This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Medicare Advantage plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Medicare Advantage retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Medicare Advantage. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.