79403
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
2.19
Facility
$156.65
Non-Facility
$156.65
Documentation Required
- For previously untreated follicular NHL: documentation that the member achieved a partial or complete response to first-line chemotherapy and documentation of timing — platelet recovery to ≥150,000/mm3 at least 6 weeks but no more than 12 weeks after the last dose of first-line chemotherapy.
- Pre-treatment and baseline laboratory documentation: platelet count and CBC results (e.g., platelet count ≥100,000/mm3; for standard dosing ≥150,000/mm3), and other relevant organ function tests as clinically indicated.
- Documentation of rituximab administration per Zevalin regimen (rituximab 250 mg/m2 IV on Day 1 and Day 7, 8, or 9) and timing of Y-90 ibritumomab tiuxetan infusion within 4 hours after the second rituximab infusion.
- Dose calculation records showing Y-90 dose (mCi/kg), and confirmation that the administered dose does not exceed the maximum allowable 32.0 mCi (1,184 MBq).
Key Coverage Criteria
- Other related CPT codes (when selection criteria are met / related to service): 78800-78804 (radiopharmaceutical localization/distribution), 85032 (manual blood count), 85049 (platelet, automated), 96401-96450 (chemotherapy administration) — billed as appropriate when selection criteria are met.
- Treatment of relapsed or refractory, low-grade or follicular B-cell non-Hodgkin's lymphoma (NHL).
- Treatment of previously untreated follicular NHL in members who have achieved a partial or complete response to first-line chemotherapy.
- Ibritumomab tiuxetan must be used along with rituximab (Rituxan) as part of the Zevalin therapeutic regimen.
- Use only as part of the Zevalin therapeutic regimen consisting of rituximab infusion on Day 1 and rituximab followed 4 hours later by Y-90 ibritumomab tiuxetan on Day 7, 8, or 9.
- CPT/Codes covered if selection criteria are met: CPT 79403 (radiopharmaceutical therapy, radiolabeled monoclonal antibody by intravenous infusion).
4 Active Policies
CARELON-therapeutic-radiopharmaceuticals-2025-03-23 — Therapeutic Radiopharmaceuticals
EVICORE-RADIATION-ONCOLOGY-CODING-MANUAL — EviCore Radiation Oncology Coding Manual
AETNA-CPB-0168 — Tumor Scintigraphy
AETNA-CPB-0659 — Ibritumomab Tiuxetan (Zevalin)
Related Codes
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