J1260 — Injection, dolasetron mesylate, 10 mg
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
- For home infusion/home therapy codes (S9351, S9370): documentation of emetic risk category (high, moderate) when required and clinical justification for home-based administration (S9370 limited to high or moderate risk).
- For Z51.0 and Z51.11 - Z51.12 when used for total body radiation: documentation that oral antiemetic therapy has failed or is contraindicated.
- For all HCPCS/CPT codes listed as 'covered if selection criteria are met': documentation that the patient meets the CPB selection criteria (specific selection criteria and required documentation elements are referenced but not included in this excerpt).
- Documentation of the emetogenic potential of the chemotherapy regimen (agent(s) and doses) consistent with the Appendix emetogenicity classifications (high/moderate/low/minimal).
Key Coverage Criteria
- Prevention of acute nausea or vomiting associated with initial and repeat courses of moderately and highly emetogenic cancer chemotherapy, including high-dose cisplatin (palonosetron (Aloxi) or fosaprepitant dimeglumine (Emend)).
- O21.0 - O21.9 — Excessive vomiting in pregnancy (when clinical signs of dehydration are present or nausea and vomiting have persisted more than 3 weeks and criteria A, B, and C are met)
- B20 — Human immunodeficiency virus [HIV] disease
- T45.1X5+ — Adverse effect of antineoplastic and immunosuppressive drugs (note: not covered for Anzemet per CPB)
- Ondansetron or other 5-HT3 antagonists as pharmacologic options in refractory nausea and vomiting of pregnancy after first-line measures per ACOG; ondansetron may be tried in refractory cases as a last resort (ACOG-referenced).
- Use of 5-HT3 receptor antagonists for management of postoperative nausea and vomiting and chemotherapy/radiotherapy-induced nausea and vomiting according to published guidelines (NCCN, ASCO, MASCC).
1 Active Policy
AETNA-CPB-0724 — Antiemetic Therapy
Related Codes
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