A9600 — Strontium sr-89 chloride, therapeutic, per millicurie
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Precertification of strontium chloride Sr-89 (Metastron) is required; submit Statement of Medical Necessity (SMN) precertification forms via Aetna Specialty Pharmacy Precertification (phone/fax provided in policy).
- Documentation demonstrating a malignant/cancer diagnosis and presence of bone metastases (e.g., pathology, imaging reports, oncologist notes).
- Evidence of pain attributable to skeletal metastases (definite signs of discomfort from skeletal metastases) and, where applicable, documentation of inadequate relief with other forms of therapy (e.g., chemotherapy, hormone therapy, analgesics).
- Baseline hematologic test results prior to therapy: white blood cell count and platelet count documentation (product guidance: WBC >2,400–3,000/µL and platelets >40–100 x 10^9/L; document any cautions if values are near/under suggested thresholds).
Key Coverage Criteria
- Relief of bone pain in members with a malignant/cancer diagnosis who have bone metastases (Aetna criteria for initial approval: both conditions required).
- Continuation of strontium chloride Sr-89 (Metastron) therapy for members previously authorized for the indication above when there is no evidence of unacceptable toxicity while on the current regimen.
- FDA‑approved indication: relief of bone pain in patients with painful skeletal metastases.
- Patients with definite signs of discomfort from skeletal metastases and with inadequate relief with other forms of therapy (e.g., chemotherapy, hormone therapy, and analgesics).
- HCPCS/ICD-10: Use may be billed/covered when selection criteria are met for ICD-10 codes C40.00–C41.9 (malignant neoplasm of bone and articular cartilage [osteosarcoma]) and C79.51–C79.52 (secondary malignant neoplasm of bone and bone marrow).
- CPT/HCPCS: Radiopharmaceutical therapy administration code 79101 and HCPCS A9600 (Strontium Sr-89 chloride, therapeutic, per millicurie) covered if selection criteria are met.
2 Active Policies
AETNA-CPB-0361 — Strontium Chloride Sr-89 (Metastron)
CARELON-therapeutic-radiopharmaceuticals-2025-03-23 — Therapeutic Radiopharmaceuticals
Related Codes
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