Recent articles in the media indicate that bevacizumab (Avastin™) is being used for intravitreal injection in the treatment of age-related macular degeneration (AMD).

This is an off-label use, and is considered investigational since there are no studies supporting this use available in the peer-reviewed literature. Under section 1862(a)(1)(A) of the Social Security Act, such usage is not reimbursable by Medicare, and is denied as not medically necessary. Additionally, all other services related to a noncovered service are also not reimbursable. Therefore, Medicare will also deny reimbursement for the intravitreal injection to administer this drug.

Providers administering bevacizumab intravitreally for AMD and submitting the claim to Medicare, should code the drug as J3490 (unclassified drugs). The phrase “ Avastin for macular degeneration” or “bevacizumab for macular degeneration” should be entered in Item 19 of the CMS-1500 form or the electronic equivalent. The intravitreal injection should be coded as 67028.

Both services should be billed with a GA modifier if a signed Advance Beneficiary Notice (ABN) was obtained from the beneficiary prior to the administration of the drug, or with a GZ modifier if an ABN was not obtained. The patient may be billed for the drug and injection only if an ABN was properly obtained.

Posted: 12/15/2005

CPT codes, descriptions, and other data only are copyright 2005 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply.