C85.16 — Unspecified B-cell lymphoma, intrapelvic lymph nodes
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- When reporting the JW modifier for discarded drug, the medical record must clearly show the amount administered and the amount wasted.
- Medical record must document prior anthracycline therapy for patients receiving albumin-bound paclitaxel, or clearly document a clinical contraindication to anthracycline therapy.
- For claims with no discarded amounts from single-dose containers or single-use packages, include the JZ modifier as evidence on the claim (effective July 1, 2023).
- Document dose and frequency as consistent with the FDA label or recognized compendia for the indication (including citations to the compendia if used for off-label indications).
Key Coverage Criteria
- Paclitaxel administered intravenously is covered for antineoplastic (cancer) indications when used in accordance with the FDA-approved labeling.
- Off-label uses of paclitaxel are covered when supported by recognized compendia (e.g., NCCN, AHFS, Clinical Pharmacology, Lexi-Drugs, Micromedex) and dosing/frequency follow those compendia.
- Albumin-bound paclitaxel (Abraxane) is covered when prior therapy included an anthracycline unless anthracycline therapy is clinically contraindicated.
- An oral antiemetic drug is covered when it has been ordered by the treating practitioner as part of a cancer chemotherapy regimen.
- An oral antiemetic drug is covered when the drug is FDA‑approved for use as an antiemetic.
- An oral antiemetic drug is covered when it is used as a full therapeutic replacement for an intravenous antiemetic that would otherwise have been administered at the time of the chemotherapy treatment.
20 Active Policies
L38835 — MolDX: Minimal Residual Disease Testing for Cancer
J05
A59259 — Billing and Coding: Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin's and Non-Hodgkin's Lymphoma with B-cell or T-cell Origin
J05
A59004 — Billing and Coding: MolDX: Minimal Residual Disease Testing for Hematologic Cancers
J05
L39477 — Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin's and Non-Hodgkin's Lymphoma with B-cell or T-cell Origin
J05
Related Codes
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