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MP 5.01.103 Bevacizumab (Avastin®) Intravitreal Use

Medical Policy
Section
Prescription Drug
 
Original Policy Date
03/2010
Last Review Status/Date
Created with literature search/3:2010
 
Issue
3:2010
Return to Medical Policy Index

Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.


Policy

Clinical use of bevacizumab as a treatment for uses other than exudative (wet) senile macular degeneration has clearly outpaced the maturation of supportive literature. However, given the potential benefit of these injections, particularly as compared to the devastating visual impact of the disease processes being treated as well as the current assessment of outcomes, Blue Cross of Idaho has decided that Bevacizumab (Avastin®) by intravitreal injection may be considered medically necessary for patients with the following conditions:

ICD-9-CM Code

Description

362.01

Background diabetic retinopathy

362.02

Proliferative Diabetic Retinopathy

362.03

Nonproliferative diabetic retinopathy, NOS

362.04

Mild nonproliferative diabetic retinopathy

362.05

Moderate nonproliferative diabetic retinopathy

362.06

Severe nonproliferative diabetic retinopathy

362.07

Diabetic macular edema

362.15

Retinal telangiectasia

362.16*

Retinal neovascularization NOS 9choroidal, subretinal)

362.29

Other non-diabetic proliferative retinopathy

362.30

Retinal vascular occlusion, unspecified

362.35

Central retinal vein occlusion

362.36

Venous tributary (branch) occlusion

362.52

Exudative (wet) senile macular degeneration

362.53

Cystoid macular degeneration (cystoid macular edema)

362.83

Retinal edema

362.84

Retinal ischemia

364.42

Rubeosis Iridis (neovascularization of iris or ciliray body)

365.63

Glaucoma associated with vascular disorders (e.g., neovascular glaucoma)

365.89

Other specified glaucoma

*Requires secondary code describing cause:

ICD-9-CM Code

Description 

115.02

Infection by Histoplasma capsulatum retinitis 

115.12

Infection by Histoplasma duboisii retinitis

115.92

Histoplasmosis retinitis, unspecified 

360.21

Progressive high (degenerative) myopia

For use of Avastin in patients with wet Macular Degeneration (AMD) please see Medical Policy 5.01.98

Please note that this policy is also applicable to our Medicare Advantage members.


Codes

Number

Description

CPT 67028 Intravitreal injection of a pharmacologic agent (separate procedure) 
HCPCS  J3590 Unclassified biologics
J9035 Injection, bevacizumab, 10 mg
Place of Service  Outpatient 
Physician’s Office
 

Policy History

Date Action Reason
03/01/10 Add to Prescription Drug section New policy


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