A9606 — Radium ra-223 dichloride, therapeutic, per microcurie
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Narrative field or electronic equivalent on the claim must state 'visceral metastases are absent'.
- Submit HCPCS code A9606 on the claim for radium Ra 223 dichloride (Xofigo).
- Diagnosis codes on the claim must include ICD-10 C61 (malignant neoplasm of prostate) and either C79.51 (secondary malignant neoplasm of bone) or C79.52 (secondary malignant neoplasm of bone marrow).
- Physician attestation is required when requesting a non-preferred product: physician must attest that the same intolerance, contraindication, or adverse event would not be expected to occur with the respective non-preferred product.
Key Coverage Criteria
- Treatment of patients with castration-resistant prostate cancer with symptomatic bone metastases and no known visceral metastatic disease.
- This policy provides parameters for coverage of injectable oncology medications (including, but not limited to octreotide acetate, leuprolide acetate, leucovorin, and levoleucovorin), including therapeutic radiopharmaceuticals, covered under the medical benefit based upon the National Comprehensive Cancer Network (NCCN) Drugs & Biologics Compendium® (NCCN Compendium®).
- UnitedHealthcare recognizes indications and uses of injectable oncology medications, including therapeutic radiopharmaceuticals, listed in the NCCN Drugs and Biologics Compendium with Categories of Evidence and Consensus of 1, 2A, and 2B as proven and medically necessary, and Categories of Evidence and Consensus of 3 as unproven and not medically necessary.
- UnitedHealthcare will cover all chemotherapy agents for individuals under the age of 19 years for oncology indications.
- Mvasi (bevacizumab-awwb) — Indications: All oncology indications.
- Kanjinti (trastuzumab-anns), Trazimera (trastuzumab-qyyp), Ogivri (trastuzumab-dkst) as preferred alternatives to Herceptin and other trastuzumab products — Indications: All oncology indications.
9 Active Policies
N/A — N/A
JJ Part B
PALMETTO-N/A — N/A
JJ Part B
A54559 — Billing and Coding: Xofigo Billing Instructions
UMR-POL-UMR-oncology-medication-clinical-coverage-policy — Oncology Medication Clinical Coverage
SUREST-POL-SUREST-oncology-medication-clinical-coverage-policy
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.