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Asset Publisher
Macugen® (pegaptanib)
Policy Number: PH-0081
Intravitreal
Last Review Date: 10/03/2022
Date of Origin: 01/01/2012
Dates Reviewed: 03/2012, 06/2012, 09/2012, 12/2012, 03/2013, 06/2013, 09/2013, 12/2013, 03/2014, 06/2014, 09/2014, 12/2014, 03/2015, 06/2015, 09/2015, 03/2016, 05/2016, 09/2016, 12/2016, 03/2017, 06/2017, 09/2017, 12/2017, 03/2018, 06/2018, 10/2018, 10/2019, 10/2020, 10/2021, 10/2022
FOR PEEHIP Members Only -Coverage excludes the provider-administered medication(s) outlined in this drug policy from being accessed through a specialty pharmacy. It must be obtained through buy and bill. |
- Length of Authorization
Coverage will be provided annually and may be renewed.
- Dosing Limits
A. Quantity Limit (max daily dose) [NDC unit]:
- 0.3 mg injection: 1 injection per eye every 42 days
B. Max Units (per dose and over time) [HCPCS Unit]:
- 2 billable units every 42 days
(Max units are based on administration to both eyes)
- Initial Approval Criteria 1-14
Coverage is provided in the following conditions:
- Patient is at least 18 years of age; AND
Universal Criteria
- Patient is free of ocular and/or peri-ocular infections; AND
- Therapy will not be used with other ophthalmic VEGF inhibitors (i.e., aflibercept, ranibizumab, brolucizumab-dbll, bevacizumab, faricimab-svoa, etc.); AND
- Patient’s best corrected visual acuity (BCVA) is measured at baseline and periodically during treatment; AND
- Patient has a definitive diagnosis of one of the following:
Neovascular (Wet) Age-Related Macular Degeneration (AMD) †
Diabetic Macular Edema (DME) ‡
Diabetic Retinopathy (DR) ‡
† FDA Approved Indication(s); ‡ Compendium recommended indication(s); Ф Orphan Drug
- Renewal Criteria 1-14
Coverage can be renewed based upon the following criteria:
- Patient continues to meet the universal and indication-specific relevant criteria as identified in section III; AND
- Absence of unacceptable toxicity from the drug. Examples of unacceptable toxicity include: endophthalmitis, increase in intraocular pressure, anaphylaxis/anaphylactoid reactions, etc.; AND
- Patient has had a beneficial response to therapy (e.g., improvement in the baseline best corrected visual acuity (BCVA), etc.) and continued administration is necessary for the maintenance treatment of the condition
- Dosage/Administration 1
Indication |
Dose |
All Indications |
Administer 0.3 mg intravitreally once every 6 weeks into the eye to be treated** **NOTE: The safety and efficacy of administration to both eyes concurrently have not been established |
- Billing Code/Availability Information
HCPCS Code:
J2503 – Injection, pegaptanib sodium, 0.3 mg; 1 billable unit = 0.3 mg
NDC:
Macugen 0.3 mg Solution for Injection: 68782-0001-xx
- References
- Macugen [package insert]. Bridgewater, NJ; Valeant Pharmaceuticals North America LLC; July 2016. Accessed September 2022.
- Cunningham ET Jr, Adamis AP, Altaweel M, et al. A phase II randomized double-masked trial of pegaptanib, an anti-vascular endothelial growth factor aptamer, for diabetic macular edema. Ophthalmology 2005;112:1747-57.
- Gonzalez VH, Giuliari GP, Banda RM, et al. Intravitreal injection of pegaptanib sodium for proliferative diabetic retinopathy. Br J Ophthalmol 2009;93:1474-78.
- Cunningham ET Jr, Adamis AP, Altaweel M, et al. A phase II randomized double-masked trial of pegaptanib, an anti-vascular endothelial growth factor aptamer, for diabetic macular edema. Ophthalmology 2005;112:1747-57.
- Adamis AP, Altaweel M, Bressler NM, et al. Changes in retinal neovascularization after pegaptanib (Macugen) therapy in diabetic individuals. Ophthalmology 2006;113:23–8.
- Hornan D, Edmeades N, Krishnan R, et al. Use of pegaptanib for recurrent and non-clearing vitreous haemorrhage in proliferative diabetic retinopathy. Eye (Lond) 2010;24(8):1315-19.
- Nishimura Y, Taguchi M, Nagai T, et al. Comparison of the effect between pegaptanib and ranibizumab on exudative age-related macular degeneration with small lesion size. Clin Ophthalmol. 2012; 6: 365–368.
- Colquitt JL, Jones J, Tan SC, et al. Ranibizumab and pegaptanib for the treatment of age-related macular degeneration: a systematic review and economic evaluation. 2008. In: Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK76206/
- Solomon SD, Chew E, Duh EJ, et al. Diabetic Retinopathy: A Position Statement by the American Diabetes Association. Diabetes Care. 2017 Mar;40(3):412-418.
- American Academy of Ophthalmology-Preferred Practice Patterns (AAO-PPP) Retina/Vitreous Committee, Hoskins Center for Quality Eye Care. Diabetic Retinopathy PPP – Update 2019. Oct 2019.
- American Academy of Ophthalmology-Preferred Practice Patterns (AAO-PPP) Retina/Vitreous Committee, Hoskins Center for Quality Eye Care. Retinal Vein Occlusions PPP – Update 2019. Oct 2019.
- American Academy of Ophthalmology-Preferred Practice Patterns (AAO-PPP) Retina/Vitreous Committee, Hoskins Center for Quality Eye Care. Age-Related Macular Degeneration PPP – Update 2019. Oct 2019.
- Royal College of Ophthalmologists. Clinical Guidelines – Retinal Vein Occlusion (RVO) Guidelines – July 2015. Accessed at https://www.rcophth.ac.uk/standards-publications-research/clinical-guidelines.
- Clinical Trial Group, Chakravarthy U, Adamis AP, et al. Year 2 efficacy results of 2 randomized controlled clinical trials of pegaptanib for neovascular age-related macular degeneration. Ophthalmology. 2006;113(9): doi:10.1016/j.ophtha.2006.02.064
- First Coast Service Options, Inc. Local Coverage Article: Billing and Coding: Vascular Endothelial Growth Factor Inhibitors for the Treatment of Ophthalmological Diseases (A56716). Centers for Medicare & Medicaid Services, Inc. Updated on 07/29/2022 with effective date of 07/01/2022. Accessed September 2022.
Appendix 1 – Covered Diagnosis Codes
ICD-10 |
ICD-10 Description |
E08.311 |
Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema |
E08.319 |
Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy without macular edema |
E08.3211 |
Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, right eye |
E08.3212 |
Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, left eye |
E08.3213 |
Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, bilateral |
E08.3219 |
Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye |
E08.3291 |
Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, right eye |
E08.3292 |
Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, left eye |
E08.3293 |
Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, bilateral |
E08.3299 |
Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye |
E08.3311 |
Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, right eye |
E08.3312 |
Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, left eye |
E08.3313 |
Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, bilateral |
E08.3319 |
Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye |
E08.3391 |
Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, right eye |
E08.3392 |
Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, left eye |
E08.3393 |
Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, bilateral |
E08.3399 |
Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye |
E08.3411 |
Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, right eye |
E08.3412 |
Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, left eye |
E08.3413 |
Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, bilateral |
E08.3419 |
Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye |
E08.3491 |
Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, right eye |
E08.3492 |
Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, left eye |
E08.3493 |
Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, bilateral |
E08.3499 |
Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye |
E08.3511 |
Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, right eye |
E08.3512 |
Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, left eye |
E08.3513 |
Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, bilateral |
E08.3519 |
Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, unspecified eye |
E08.3521 |
Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye |
E08.3522 |
Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye |
E08.3523 |
Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral |
E08.3529 |
Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye |
E08.3531 |
Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye |
E08.3532 |
Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye |
E08.3533 |
Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral |
E08.3539 |
Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye |
E08.3541 |
Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye |
E08.3542 |
Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye |
E08.3543 |
Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral |
E08.3549 |
Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye |
E08.3551 |
Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, right eye |
E08.3552 |
Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, left eye |
E08.3553 |
Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, bilateral |
E08.3559 |
Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, unspecified eye |
E08.3591 |
Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, right eye |
E08.3592 |
Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, left eye |
E08.3593 |
Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, bilateral |
E08.3599 |
Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, unspecified eye |
E08.37X1 |
Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, right eye |
E08.37X2 |
Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, left eye |
E08.37X3 |
Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, bilateral |
E08.37X9 |
Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, unspecified eye |
E09.311 |
Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular edema |
E09.319 |
Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy without macular edema |
E09.3211 |
Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye |
E09.3212 |
Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye |
E09.3213 |
Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral |
E09.3219 |
Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye |
E09.3291 |
Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye |
E09.3292 |
Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye |
E09.3293 |
Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral |
E09.3299 |
Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye |
E09.3311 |
Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye |
E09.3312 |
Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye |
E09.3313 |
Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral |
E09.3319 |
Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye |
E09.3391 |
Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye |
E09.3392 |
Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye |
E09.3393 |
Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral |
E09.3399 |
Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye |
E09.3411 |
Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye |
E09.3412 |
Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye |
E09.3413 |
Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral |
E09.3419 |
Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye |
E09.3491 |
Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye |
E09.3492 |
Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye |
E09.3493 |
Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral |
E09.3499 |
Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye |
E09.3511 |
Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye |
E09.3512 |
Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye |
E09.3513 |
Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral |
E09.3519 |
Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye |
E09.3521 |
Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye |
E09.3522 |
Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye |
E09.3523 |
Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral |
E09.3529 |
Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye |
E09.3531 |
Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye |
E09.3532 |
Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye |
E09.3533 |
Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral |
E09.3539 |
Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye |
E09.3541 |
Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye |
E09.3542 |
Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye |
E09.3543 |
Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral |
E09.3549 |
Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye |
E09.3551 |
Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, right eye |
E09.3552 |
Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, left eye |
E09.3553 |
Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, bilateral |
E09.3559 |
Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eye |
E09.3591 |
Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye |
E09.3592 |
Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye |
E09.3593 |
Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral |
E09.3599 |
Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified eye |
E09.37X1 |
Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, right eye |
E09.37X2 |
Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, left eye |
E09.37X3 |
Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral |
E09.37X9 |
Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, unspecified eye |
E10.311 |
Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema |
E10.319 |
Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema |
E10.3211 |
Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye |
E10.3212 |
Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye |
E10.3213 |
Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral |
E10.3219 |
Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye |
E10.3291 |
Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye |
E10.3292 |
Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye |
E10.3293 |
Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral |
E10.3299 |
Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye |
E10.3311 |
Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye |
E10.3312 |
Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye |
E10.3313 |
Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral |
E10.3319 |
Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye |
E10.3391 |
Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye |
E10.3392 |
Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye |
E10.3393 |
Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral |
E10.3399 |
Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye |
E10.3411 |
Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye |
E10.3412 |
Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye |
E10.3413 |
Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral |
E10.3419 |
Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye |
E10.3491 |
Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye |
E10.3492 |
Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye |
E10.3493 |
Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral |
E10.3499 |
Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye |
E10.3511 |
Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye |
E10.3512 |
Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye |
E10.3513 |
Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral |
E10.3519 |
Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye |
E10.3521 |
Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye |
E10.3522 |
Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye |
E10.3523 |
Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral |
E10.3529 |
Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye |
E10.3531 |
Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye |
E10.3532 |
Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye |
E10.3533 |
Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral |
E10.3539 |
Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye |
E10.3541 |
Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye |
E10.3542 |
Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye |
E10.3543 |
Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral |
E10.3549 |
Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye |
E10.3551 |
Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, right eye |
E10.3552 |
Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, left eye |
E10.3553 |
Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral |
E10.3559 |
Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eye |
E10.3591 |
Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye |
E10.3592 |
Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye |
E10.3593 |
Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral |
E10.3599 |
Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified eye |
E10.37X1 |
Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, right eye |
E10.37X2 |
Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, left eye |
E10.37X3 |
Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral |
E10.37X9 |
Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, unspecified eye |
E11.311 |
Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema |
E11.319 |
Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema |
E11.3211 |
Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye |
E11.3212 |
Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye |
E11.3213 |
Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral |
E11.3219 |
Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye |
E11.3291 |
Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye |
E11.3292 |
Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye |
E11.3293 |
Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral |
E11.3299 |
Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye |
E11.3311 |
Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye |
E11.3312 |
Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye |
E11.3313 |
Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral |
E11.3319 |
Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye |
E11.3391 |
Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye |
E11.3392 |
Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye |
E11.3393 |
Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral |
E11.3399 |
Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye |
E11.3411 |
Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye |
E11.3412 |
Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye |
E11.3413 |
Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral |
E11.3419 |
Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye |
E11.3491 |
Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye |
E11.3492 |
Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye |
E11.3493 |
Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral |
E11.3499 |
Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye |
E11.3511 |
Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye |
E11.3512 |
Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye |
E11.3513 |
Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral |
E11.3519 |
Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye |
E11.3521 |
Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye |
E11.3522 |
Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye |
E11.3523 |
Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral |
E11.3529 |
Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye |
E11.3531 |
Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye |
E11.3532 |
Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye |
E11.3533 |
Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral |
E11.3539 |
Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye |
E11.3541 |
Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye |
E11.3542 |
Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye |
E11.3543 |
Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral |
E11.3549 |
Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye |
E11.3551 |
Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, right eye |
E11.3552 |
Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, left eye |
E11.3553 |
Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral |
E11.3559 |
Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eye |
E11.3591 |
Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye |
E11.3592 |
Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye |
E11.3593 |
Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral |
E11.3599 |
Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified eye |
E11.37X1 |
Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, right eye |
E11.37X2 |
Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, left eye |
E11.37X3 |
Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral |
E11.37X9 |
Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, unspecified eye |
E13.311 |
Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema |
E13.319 |
Other specified diabetes mellitus with unspecified diabetic retinopathy without macular edema |
E13.3211 |
Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye |
E13.3212 |
Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye |
E13.3213 |
Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral |
E13.3219 |
Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye |
E13.3291 |
Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye |
E13.3292 |
Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye |
E13.3293 |
Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral |
E13.3299 |
Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye |
E13.3311 |
Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye |
E13.3312 |
Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye |
E13.3313 |
Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral |
E13.3319 |
Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye |
E13.3391 |
Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye |
E13.3392 |
Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye |
E13.3393 |
Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral |
E13.3399 |
Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye |
E13.3411 |
Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye |
E13.3412 |
Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye |
E13.3413 |
Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral |
E13.3419 |
Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye |
E13.3491 |
Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye |
E13.3492 |
Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye |
E13.3493 |
Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral |
E13.3499 |
Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye |
E13.3511 |
Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye |
E13.3512 |
Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye |
E13.3513 |
Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral |
E13.3519 |
Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye |
E13.3521 |
Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye |
E13.3522 |
Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye |
E13.3523 |
Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral |
E13.3529 |
Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye |
E13.3531 |
Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye |
E13.3532 |
Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye |
E13.3533 |
Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral |
E13.3539 |
Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye |
E13.3541 |
Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye |
E13.3542 |
Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye |
E13.3543 |
Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral |
E13.3549 |
Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye |
E13.3551 |
Other specified diabetes mellitus with stable proliferative diabetic retinopathy, right eye |
E13.3552 |
Other specified diabetes mellitus with stable proliferative diabetic retinopathy, left eye |
E13.3553 |
Other specified diabetes mellitus with stable proliferative diabetic retinopathy, bilateral |
E13.3559 |
Other specified diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eye |
E13.3591 |
Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye |
E13.3592 |
Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye |
E13.3593 |
Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral |
E13.3599 |
Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified eye |
E13.37X1 |
Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, right eye |
E13.37X2 |
Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, left eye |
E13.37X3 |
Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral |
E13.37X9 |
Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, unspecified eye |
H35.3210 |
Exudative age-related macular degeneration, right eye, stage unspecified |
H35.3211 |
Exudative age-related macular degeneration, right eye, with active choroidal neovascularization |
H35.3212 |
Exudative age-related macular degeneration, right eye, with inactive choroidal neovascularization |
H35.3213 |
Exudative age-related macular degeneration, right eye, with inactive scar |
H35.3220 |
Exudative age-related macular degeneration, left eye, stage unspecified |
H35.3221 |
Exudative age-related macular degeneration, left eye, with active choroidal neovascularization |
H35.3222 |
Exudative age-related macular degeneration, left eye, with inactive choroidal neovascularization |
H35.3223 |
Exudative age-related macular degeneration, left eye, with inactive scar |
H35.3230 |
Exudative age-related macular degeneration, bilateral, stage unspecified |
H35.3231 |
Exudative age-related macular degeneration, bilateral, with active choroidal neovascularization |
H35.3232 |
Exudative age-related macular degeneration, bilateral, with inactive choroidal neovascularization |
H35.3233 |
Exudative age-related macular degeneration, bilateral, with inactive scar |
H35.3290 |
Exudative age-related macular degeneration, unspecified eye, stage unspecified |
H35.3291 |
Exudative age-related macular degeneration, unspecified eye, with active choroidal neovascularization |
H35.3292 |
Exudative age-related macular degeneration, unspecified eye, with inactive choroidal neovascularization |
H35.3293 |
Exudative age-related macular degeneration, unspecified eye, with inactive scar |
Appendix 2 – Centers for Medicare and Medicaid Services (CMS)
Medicare coverage for outpatient (Part B) drugs is outlined in the Medicare Benefit Policy Manual (Pub. 100-2), Chapter 15, §50 Drugs and Biologicals. In addition, National Coverage Determination (NCD), Local Coverage Determinations (LCDs), and Local Coverage Articles (LCAs) may exist and compliance with these policies is required where applicable. They can be found at: https://www.cms.gov/medicare-coverage-database/search.aspx. Additional indications may be covered at the discretion of the health plan.
Medicare Part B Covered Diagnosis Codes (applicable to existing NCD/LCD/LCA):
Jurisdiction(s): N (9) |
NCD/LCD Document (s): A56716 |
Medicare Part B Administrative Contractor (MAC) Jurisdictions |
||
Jurisdiction |
Applicable State/US Territory |
Contractor |
E (1) |
CA, HI, NV, AS, GU, CNMI |
Noridian Healthcare Solutions, LLC |
F (2 & 3) |
AK, WA, OR, ID, ND, SD, MT, WY, UT, AZ |
Noridian Healthcare Solutions, LLC |
5 |
KS, NE, IA, MO |
Wisconsin Physicians Service Insurance Corp (WPS) |
6 |
MN, WI, IL |
National Government Services, Inc. (NGS) |
H (4 & 7) |
LA, AR, MS, TX, OK, CO, NM |
Novitas Solutions, Inc. |
8 |
MI, IN |
Wisconsin Physicians Service Insurance Corp (WPS) |
N (9) |
FL, PR, VI |
First Coast Service Options, Inc. |
J (10) |
TN, GA, AL |
Palmetto GBA, LLC |
M (11) |
NC, SC, WV, VA (excluding below) |
Palmetto GBA, LLC |
L (12) |
DE, MD, PA, NJ, DC (includes Arlington & Fairfax counties and the city of Alexandria in VA) |
Novitas Solutions, Inc. |
K (13 & 14) |
NY, CT, MA, RI, VT, ME, NH |
National Government Services, Inc. (NGS) |
15 |
KY, OH |
CGS Administrators, LLC |