D48.9 — Neoplasm of uncertain behavior, unspecified
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- A written, signed, and dated order for the oral anticancer drug must be received by the supplier before submitting the claim.
- The ICD-10 diagnosis code describing the condition for which the drug is used must be included on each claim.
- Claims for J8498 or J8597 must identify the drug name, manufacturer, and dosage strength of each tablet/suppository and must indicate which oral anticancer drug is being used and the prescribed frequency in the narrative field of an electronic claim.
- Suppliers must use the NDC that matches the product dispensed and follow NCPDP/NDC billing instructions when submitting claims in NCPDP format.
Key Coverage Criteria
- An oral anticancer drug is covered only if it is an FDA-approved drug or biological and meets all other Medicare statutory/regulatory requirements.
- The oral drug must have the same active ingredient and the same chemical/generic name as a non-self-administrable anticancer drug or be a prodrug metabolized to the same active ingredient as the covered non-self-administerable form.
- The oral anticancer drug must be used for the same anticancer chemotherapeutic indications (including off-label uses) as the non-self-administerable form.
- The oral anticancer drug must be prescribed by a practitioner licensed under state law to prescribe anticancer chemotherapeutic agents and a written, signed, and dated order must be received by the supplier before claim submission.
- A self-administered antiemetic billed with HCPCS J8498 or J8597 is covered when it is used with a covered oral anticancer drug, is likely needed to prevent emesis from that anticancer drug, and is administered within 2 hours before the oral anticancer drug.
- Administration of erythropoiesis stimulating agents (ESAs) billed with HCPCS J0881, J0882, J0885, J0886, Q4081, Q5105, or Q5106 for patients with anemia related to ESRD, chronic kidney disease (CKD), chemotherapy, radiation, or myelodysplastic syndrome (MDS), when the use meets the coverage criteria in the applicable LCD.
12 Active Policies
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A52479 — Oral Anticancer Drugs - Policy Article
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