J2469, Injection, palonosetron hcl, 25 mcg
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- For non-preferred product approval: documentation of a prior trial (adequate dose and duration) of a preferred NK1 RA or 5HT3 RA and documentation of minimal clinical response to that trial.
- Alternatively, for non-preferred product approval: documentation of history of intolerance, contraindication, or adverse event to a preferred NK1 RA or 5HT3 RA, plus physician attestation that the same intolerance/contraindication/adverse event would not be expected with the requested non-preferred product.
- Physician attestation (statement in medical record) supporting expectation of superior clinical response with non-preferred product (when trial/failure route used) or supporting that intolerance/contraindication to preferred product would not occur with non-preferred product.
Key Coverage Criteria
- Prevention of chemotherapy-induced nausea and vomiting (CINV) due to High Emetic Risk parenteral anticancer agents when an NK1 RA (e.g., Emend, Cinvanti, Varubi) is used in combination with a 5HT3 RA.
- Prevention of CINV due to Moderate Emetic Risk parenteral anticancer agents when an NK1 RA is used in combination with a 5HT3 RA and the patient has one or more CINV risk factors (younger age <55 years; female sex; previous history of chemotherapy-induced nausea/vomiting; little or no previous alcohol use; history of motion sickness or morning sickness during pregnancy; high anxiety).
- Prevention of CINV due to High Emetic Risk parenteral anticancer agents when a 5HT3 RA (Aloxi, Kytril, Sustol, Zofran) is used in combination with an NK1 RA.
- Prevention of CINV due to Moderate Emetic Risk parenteral anticancer agents when a 5HT3 RA is used (standalone option for moderate risk).
- Prevention of CINV due to Moderate Emetic Risk parenteral anticancer agents when a 5HT3 RA is used in combination with an NK1 RA and the patient has one or more CINV risk factors (younger age <55 years; female sex; previous history of chemotherapy-induced nausea/vomiting; little or no previous alcohol use; history of motion sickness or morning sickness during pregnancy; high anxiety).
- Treatment of breakthrough nausea and/or vomiting due to anticancer agent(s) (5HT3 RAs listed as indicated for this scenario).
11 Active Policies
AETNA-CPB-0724, Antiemetic Therapy
UMR-POL-UMR-antiemetics-oncology, Antiemetics for Oncology
SUREST-POL-SUREST-antiemetics-oncology, Antiemetics for Oncology
EVICORE-HPLAN-CIGNA_MEDICARE-F57DF6FC9C3C, Q1 - 2025 1199 SEIU Benefit Funds MedOnc Master Drug List
Related Codes
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