A9699 — Radiopharmaceutical, therapeutic, not otherwise classified
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
- Every Part A claim for NOC/unlisted drug, biologic, and radiopharmaceutical codes must include the appropriate NOC code and the appropriate diagnosis.
- Every claim must include the appropriate revenue codes for the drug and for IV infusion when applicable.
- Every claim must indicate the drug name, the National Drug Code (NDC) number, and the total dosage administered.
- For claim submission, the required documentation must be included in the remarks field (Field Locator 80) on the UB-04 (CMS 1450) or the equivalent 5010 electronic claim field.
Key Coverage Criteria
- For claims using not otherwise classified (NOC)/unlisted HCPCS codes J3490, J3590, J9999, A4641, or A9699 with limited or specific indications, submit required documentation in the claim remarks field (Field Locator 80 on the UB-04) or the equivalent 5010 electronic claim field so Palmetto GBA can ascertain FDA labeling indications have been met.
- For oncology drugs or oncology radiopharmaceuticals submitted with NOC codes prior to assignment of a unique HCPCS code, include the diagnosis code that corresponds to the specific FDA label indication or, if no adequate diagnosis code exists, include a specific narrative description of the indication (e.g., 'squamous cell carcinoma').
- 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.
9 Active Policies
N/A — N/A
JJ Part B
PALMETTO-N/A — N/A
JJ Part B
UHC-POL-oncology-medication-clinical-coverage-policy — Oncology Medication Clinical Coverage
UMR-POL-UMR-oncology-medication-clinical-coverage-policy — Oncology Medication Clinical Coverage
Related Codes
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