Prior Authorization
Anthem Prior Authorization for CPT 67028
Site of service - Eye and ocular adnexa procedures (outpatient hospital only) · Standard commercial plans
Source
Anthem clinical policyNot medical advice. PA policies change frequently. Always confirm against the payer's current policy before submitting. d3rx pulls directly from publicly published policy PDFs and refreshes daily.
Clinical criteria
Anthem requires prior authorization for intravitreal injection. Covered for neovascular AMD, diabetic macular edema, retinal vein occlusion with macular edema. OCT and/or fluorescein angiography required for initial diagnosis. Standard loading phase of 3 injections. Continuation based on documented response (OCT, visual acuity improvement or stabilization).
Documentation checklist
- ✓Retinal exam with OCT imaging
- ✓Fluorescein angiography (if initial diagnosis)
- ✓Visual acuity measurement
- ✓Drug name (bevacizumab, ranibizumab, aflibercept, faricimab)
- ✓Treatment response documentation for continuation
Submission channels
Phone
1-800-274-77672026 Medicare rate for CPT 67028
Office (non-facility)
$114.23
Facility
$75.49
Total RVUs (office)
3.42
Conversion factor
$33.4009
National Medicare Physician Fee Schedule amounts (GPCI 1.0). Anthem's commercial allowable is negotiated against this benchmark — see the full RVU and locality breakdown on the CPT 67028 code page.
How to submit the PA
- 1Verify the requirement against the current clinical policy linked above.
- 2Gather documentation: Retinal exam with OCT imaging, Fluorescein angiography (if initial diagnosis), Visual acuity measurement….
- 3Submit via phone, or the payer portal.
- 4Document the reference number and follow up within 5 business days if no determination is received.
FAQ
- Does Anthem require prior authorization for CPT 67028?
- Yes. Anthem requires prior authorization for CPT 67028 (Site of service - Eye and ocular adnexa procedures (outpatient hospital only)) under Standard commercial plans per its published clinical policy.
- What documentation does Anthem require for CPT 67028?
- Retinal exam with OCT imaging; Fluorescein angiography (if initial diagnosis); Visual acuity measurement; Drug name (bevacizumab, ranibizumab, aflibercept, faricimab); Treatment response documentation for continuation
- How much does Medicare pay for CPT 67028 in 2026?
- In 2026, the national Medicare allowable for CPT 67028 is $114.23 in an office setting and $75.49 in a facility. Commercial allowables for Anthem are typically negotiated against this benchmark.
- What if Anthem denies the PA for CPT 67028?
- Appeal in writing within 60 days, citing the specific clinical policy criteria the case meets and attaching supporting documentation. Many denials are reversed on first-level appeal when the criteria language is mirrored.
Other Anthem PA lookups
CPT 67028 prior authorization by payer
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