Page reviewed Jun 29, 2026 · from FDA-approved labeling (Drugs@FDA) — no drug-specific Medicare LCD
Quick answer
Medicare benefit
Part B (physician-administered)
FDA-indicated diagnoses
75 ICD-10 codes
Governing policy
FDA indications (no LCD)
Contractor (MAC)
Per medical necessity
Source
FDA labeling
Page reviewed
Jun 29, 2026
HCPCS codes covered:
J0178
J0178
No drug-specific Medicare coverage article exists for Eylea. Coverage is decided per medical necessity by your MAC. The FDA-approved indications below are the labeled uses Medicare generally pays for; an off-label use may be covered if supported by an approved compendium. Find your MAC by state →
What Medicare pays for Eylea (2026 Q2)
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:
| HCPCS | Description | Per unit | Allowed (ASP + 6%) |
|---|---|---|---|
| J0178 | Aflibercept injection | 1 mg | $731.885 |
Source: CMS ASP Drug Pricing File, 2026 Q2. 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 →
Eylea 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 J0178) 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 Eylea
The 75 ICD-10 codes below are the FDA-approved indications for J0178 — the labeled uses Medicare generally pays for under medical necessity — grouped by condition. Use the filter to find a specific code or condition.
Wet AMD (Neovascular AMD) — 4 diagnoses (applies to J0178)
Diseases of the eye & adnexa (4)
| ICD-10 | Covered diagnosis |
|---|---|
| H35.3210 | Exudative age-related macular degeneration, right eye, stage unspecified |
| H35.3220 | Exudative age-related macular degeneration, left eye, stage unspecified |
| H35.3230 | Exudative age-related macular degeneration, bilateral, stage unspecified |
| H35.3290 | Exudative age-related macular degeneration, unspecified eye, stage unspecified |
Diabetic Macular Edema (DME) — 18 diagnoses (applies to J0178)
Endocrine, nutritional & metabolic diseases (17)
| ICD-10 | Covered diagnosis |
|---|---|
| E11.311 | Type 2 diabetes mellitus with unspecified diabetic retinopathy with 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 |
| E11.3311 | 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 |
| E11.3411 | 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 |
| E11.3511 | 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 |
Diseases of the eye & adnexa (1)
| ICD-10 | Covered diagnosis |
|---|---|
| H35.81 | Retinal edema |
Diabetic Retinopathy — 17 diagnoses (applies to J0178)
Endocrine, nutritional & metabolic diseases (17)
| ICD-10 | Covered diagnosis |
|---|---|
| E11.319 | Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema |
| 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 |
| E11.3391 | 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 |
| E11.3491 | 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 |
| E11.3591 | 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 |
Macular Edema following Retinal Vein Occlusion (RVO) — 8 diagnoses (applies to J0178)
Diseases of the eye & adnexa (8)
| ICD-10 | Covered diagnosis |
|---|---|
| H34.8110 | Central retinal vein occlusion, right eye, with macular edema |
| H34.8120 | Central retinal vein occlusion, left eye, with macular edema |
| H34.8130 | Central retinal vein occlusion, bilateral, with macular edema |
| H34.8190 | Central retinal vein occlusion, unspecified eye, with macular edema |
| H34.8310 | Tributary (branch) retinal vein occlusion, right eye, with macular edema |
| H34.8320 | Tributary (branch) retinal vein occlusion, left eye, with macular edema |
| H34.8330 | Tributary (branch) retinal vein occlusion, bilateral, with macular edema |
| H34.8390 | Tributary (branch) retinal vein occlusion, unspecified eye, with macular edema |
Retinopathy of Prematurity (ROP) — 28 diagnoses (applies to J0178)
Diseases of the eye & adnexa (28)
| ICD-10 | Covered diagnosis |
|---|---|
| H35.101 | Retinopathy of prematurity, unspecified, right eye |
| H35.102 | Retinopathy of prematurity, unspecified, left eye |
| H35.103 | Retinopathy of prematurity, unspecified, bilateral |
| H35.109 | Retinopathy of prematurity, unspecified, unspecified eye |
| H35.111 | Retinopathy of prematurity, stage 0, right eye |
| H35.112 | Retinopathy of prematurity, stage 0, left eye |
| H35.113 | Retinopathy of prematurity, stage 0, bilateral |
| H35.119 | Retinopathy of prematurity, stage 0, unspecified eye |
| H35.121 | Retinopathy of prematurity, stage 1, right eye |
| H35.122 | Retinopathy of prematurity, stage 1, left eye |
| H35.123 | Retinopathy of prematurity, stage 1, bilateral |
| H35.129 | Retinopathy of prematurity, stage 1, unspecified eye |
| H35.131 | Retinopathy of prematurity, stage 2, right eye |
| H35.132 | Retinopathy of prematurity, stage 2, left eye |
| H35.133 | Retinopathy of prematurity, stage 2, bilateral |
| H35.139 | Retinopathy of prematurity, stage 2, unspecified eye |
| H35.141 | Retinopathy of prematurity, stage 3, right eye |
| H35.142 | Retinopathy of prematurity, stage 3, left eye |
| H35.143 | Retinopathy of prematurity, stage 3, bilateral |
| H35.149 | Retinopathy of prematurity, stage 3, unspecified eye |
| H35.151 | Retinopathy of prematurity, stage 4, right eye |
| H35.152 | Retinopathy of prematurity, stage 4, left eye |
| H35.153 | Retinopathy of prematurity, stage 4, bilateral |
| H35.159 | Retinopathy of prematurity, stage 4, unspecified eye |
| H35.161 | Retinopathy of prematurity, stage 5, right eye |
| H35.162 | Retinopathy of prematurity, stage 5, left eye |
| H35.163 | Retinopathy of prematurity, stage 5, bilateral |
| H35.169 | Retinopathy of prematurity, stage 5, unspecified eye |
How to use this list when billing
Put a medically necessary, FDA-indicated diagnosis from the list above on the claim line with J0178, match the correct product code and units (check JZ/JW wastage), and document medical necessity. Because there's no drug-specific LCD, coverage is judged per medical necessity by your MAC; an off-label use can still be covered if supported by an approved drug compendium.
LCD vs. Billing & Coding Article vs. NCD
An LCD (Local Coverage Determination) is a MAC's policy on whether a service is reasonable and necessary in its region, and its companion Billing & Coding Article holds the covered ICD-10 and HCPCS code lists. A NCD (National Coverage Determination), where one exists, applies nationwide. Eylea has no drug-specific LCD or Article, so there is no published covered-code list — it's covered under the general Part B drug benefit per medical necessity, and the FDA-approved indications above are the practical starting point.
Common Eylea denial reasons
| What you see | Why | Fix |
|---|---|---|
| CO-50 — not medically necessary | Diagnosis the MAC doesn’t accept as medically necessary | Bill a medically necessary FDA-indicated diagnosis from the list above; document necessity (compendium cite for off-label) |
| Diagnosis/units mismatch | Right dx but wrong product code or unit count | Match the J/Q code and units to the drug actually given (check JZ/JW wastage) |
| Off-label denial | Indication isn't FDA-labeled and isn't compendium-supported | Cite an approved compendium (e.g. DrugDex/NCCN) or appeal with literature |
| Self-administered (SAD) denial | Drug is on your MAC's self-administered exclusion list | Check the SAD list — it may be Part D, not Part B |
Frequently asked questions
- Is Eylea covered by Medicare?
- Yes. Eylea (J0178) is covered under Medicare Part B as a physician-administered drug when billed for a medically necessary indication. There is no drug-specific Local Coverage Determination (LCD) for it, so coverage is determined per medical necessity by your MAC; the FDA-approved indications below are the starting point.
- What diagnoses are covered for Eylea (J0178)?
- Medicare does not publish a drug-specific covered-diagnosis list for J0178. The 75 ICD-10 codes on this page are the FDA-approved indications — the labeled uses Medicare will generally pay for under medical necessity. Off-label uses may be covered if supported by an approved compendium.
- Which Medicare policy covers Eylea?
- No drug-specific LCD or Billing & Coding Article exists for Eylea. It's covered under the general Medicare Part B drug benefit per medical necessity, as judged by your Medicare Administrative Contractor (MAC).
- Why was my Eylea claim denied as not medically necessary?
- The most common cause is a diagnosis the MAC doesn't consider medically necessary for J0178. Bill a covered/FDA-approved indication from the list below, document medical necessity, and confirm any local guidance with your MAC.
Related references
Covered is only half the answer.
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- Source
- FDA-approved indications (Drugs@FDA labeling) mapped to ICD-10-CM. No drug-specific Medicare LCD/Article exists for Eylea — Part B coverage is determined per medical necessity by your MAC.
- CMS article last revised
- n/a — the most recent revision CMS has published for this article.
- Page last reviewed by CareCost
- Jun 29, 2026 (coverage data retrieved 2026-06-28; we re-verify against CMS quarterly).
- Code licensing
- ICD-10-CM codes are public domain (CMS/CDC). CPT® codes are AMA-copyrighted and are intentionally not listed here — see the administration-code reference for those.
- Not advice
- This is general billing reference, not legal or billing advice. Always verify against the LCD/Article that applies to your MAC and patient.
- How we build this
- Compiled programmatically from the CMS Coverage API and reviewed by the CareCost Estimate editorial team against the source article. See our methodology and editorial policy.
- Spotted an error?
- Email editorial@carecostestimate.com.