Vabysmo (J2777): Medicare covered diagnoses & ICD-10 codes

What Medicare pays for Vabysmo (2026 Q3)

Once a claim carries a covered diagnosis, Medicare Part B reimburses the drug at the ASP + 6% payment limit. Current allowed amounts per billing unit:

Source: CMS ASP Drug Pricing File, 2026 Q3. Payment = ASP + 6% per unit; multiply by units billed (watch JZ/JW wastage). Your patient's share is typically 20% after the deductible. Estimate the full cost & patient out-of-pocket →

Vabysmo is a physician-administered biologic billed under Medicare Part B (not the Part D pharmacy benefit). Under Part B, Medicare pays the practice for the drug (HCPCS J2777) plus its administration — but only when the claim's diagnosis (ICD-10) code supports medical necessity. Each MAC publishes the specific covered diagnoses in a Billing & Coding Article; a claim with a diagnosis outside that list is typically denied as not medically necessary (CO-50).

Covered ICD-10 diagnoses for Vabysmo

The 96 codes below are the diagnoses Wellpoint Federal accepts for J2777 under Article A52451, grouped exactly as CMS groups them and organized by condition category for scanning. Use the filter in each group to find a specific code or condition.

What commercial payers require for Vabysmo

Medicare Part B is only half the answer — most Vabysmo claims are adjudicated by a commercial plan with its own medical policy. Below is what 27 commercial payers publish for Vabysmo, read from each payer's own policy document. 18 of 27 that state a position require prior authorization, and 4 run a site-of-care program that can push the infusion out of the hospital outpatient setting.

What Vabysmo payers put in writing

Quoted from the medical policies linked above — 24 distinct requirements across 27 payers. These are the sentences an appeal has to answer.

Clinical prerequisites — what must be true before they pay

• Prescribed by or in consultation with an ophthalmologist— BCBS Kansas, BCBS South Carolina, Centene / Ambetter policy ↗
• Patient is at least 18 years of age— BCBS Minnesota, Capital BlueCross policy ↗
• Initial request must be for a preferred product.— Arkansas BCBS policy ↗
• Age 18 years of age or older— BCBS Federal Employee Program policy ↗
• VEGF inhibitors must only be administered by a retina trained ophthalmologist— BCBS Federal Employee Program policy ↗
• NOT used in combination with other vascular endothelial growth factor (VEGF) inhibitors for ocular indications— BCBS Federal Employee Program policy ↗

Prior authorization

• INITIAL AND CONTINUATION APPROVAL will be for duration of the treatment course or 12 months— Arkansas BCBS policy ↗
• Prior approval is required to ensure the safe, clinically appropriate, and cost-effective use of VEGF Inhibitors— BCBS Federal Employee Program policy ↗
• Vabysmo (faricimab) * Covered under Medical Benefit Only, PA Prior Authorization required— BCBS Massachusetts policy ↗
• Line of Business PA Required in Medical Management System (Yes/No) BCBS Yes BCN Yes MAPPO Yes BCNA Yes— BCBS Michigan policy ↗
• Requests must be supported by submission of chart notes and patient specific documentation.— BCBS Michigan policy ↗
• Prior authorization validity will be provided initially for 12 months, unless otherwise— BCBS Minnesota policy ↗

Quantity and frequency limits

• Quantity Limits: Align with FDA recommended dosing— BCBS Michigan policy ↗
• Administer 6 mg intravitreally per affected eye once every 4 weeks (approximately— BCBS Minnesota policy ↗
• When a request for a specialty drug is approved, coverage is based on a trial of therapy concept. The drug will be initially approved for 3 months. Specific measurable response(s) should be identified and documented at the time of initial approval. Continuation of the drug is covered for an additional 12 months if the patient demonstrates a measurable response.— HMSA (BCBS Hawaii) policy ↗
• Authorization is for no more than 12 months— UnitedHealthcare policy ↗

Dosing rules

• (Beovu) Brolucizumab is available as Beovu 6 mg/0.05 mL solution for intravitreal— Aetna policy ↗
• 6 mg per eye; each eye may be treated as frequently as every 4 weeks— Anthem / Elevance policy ↗
• The dose does not exceed 6 mg every 4 weeks— BCBS Louisiana policy ↗
• Diabetic macular edema and diabetic retinopathy: 6 mg administered via intravitreal injection every 4 weeks for the first 4 doses.— BCBS Nebraska policy ↗
• Not to exceed 6 mg administered by intravitreal injection given as often as every 3 weeks— Blue Shield of California policy ↗
• Degeneration (nAMD) Initiation: • Administer 6 mg intravitreally per affected— Capital BlueCross policy ↗

Reauthorization / continuation

• Clinical documentation must be provided to confirm that current criteria are met and that the medication is providing clinical benefit— BCBS Michigan policy ↗
• When a request for a specialty drug is approved, coverage is based on a trial of therapy concept. The drug will be initially approved for 3 months. Specific measurable response(s) should be identified and documented at the time of initial approval. Continuation of the drug is covered for an additional 12 months if the patient demonstrates a measurable response.— HMSA (BCBS Hawaii) policy ↗

Read from each payer's published medical policy between 2026-08-03 and 2026-08-13. Every requirement above is quoted from the policy it links to. Commercial policy changes without notice — confirm before you bill.

How to bill Vabysmo

Put the patient's covered ICD-10 diagnosis on the claim line with J2777. Matching codes, units and JZ/JW wastage →

Which policy governs Vabysmo

The covered code lists live in Article A52451 (tied to LCD L33394) — CMS moved code lists out of LCDs and into Articles, which is why the diagnoses live in the Article. What an LCD, an Article and an NCD each govern →

If a claim for Vabysmo is denied

The usual cause is a diagnosis outside Article A52451's covered list, or a product code and unit count that do not match what was given. The five denial patterns and how to fix each →