J3260, Injection, tobramycin sulfate, up to 80 mg
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
- Documentation of diagnosis of cystic fibrosis confirmed by appropriate diagnostic or genetic testing.
- Documentation of lung infection with positive identification of Pseudomonas aeruginosa by culture or DNA testing.
- Documentation that the individual does not have a hypersensitivity to any aminoglycoside (allergy history or contraindication noted in chart).
- "Presence of Pseudomonas aeruginosa in culture of the airway (e.g., sputum culture, oropharyngeal culture, bronchoalveolar lavage culture)" — culture results must be documented.
Key Coverage Criteria
- Management of cystic fibrosis in individuals with Pseudomonas aeruginosa (FDA-approved indication).
- Management of cystic fibrosis in individuals with Pseudomonas aeruginosa. (FDA-approved indication)
- Treatment of bronchiectasis in individuals with Pseudomonas aeruginosa. (Approved off-label compendial use)
- Cystic fibrosis — approval contingent on: "Presence of Pseudomonas aeruginosa in culture of the airway (e.g., sputum culture, oropharyngeal culture, bronchoalveolar lavage culture); AND Tobramycin inhalation product is prescribed by or in consultation with a pulmonologist or a physician who specializes in the treatment of cystic fibrosis."
- Bronchiectasis, non-cystic fibrosis, with Pseudomonas aeruginosa — approval contingent on: "Presence of Pseudomonas aeruginosa in culture of the airway (e.g., sputum culture, oropharyngeal culture, bronchoalveolar lavage culture); Is 18 years of age or older; AND Tobramycin inhalation product is prescribed by or in consultation with a pulmonologist."
5 Active Policies
BCBSLA-00519-1457B6F31A, 00519 Inhaled Antibiotics for Cystic Fibrosis (tobramycin, Tobi, Tobi Podhaler, Bethkis, Cayston)
LA
POINT32HEALTH-PMNG-16676, Tobi Podhaler (tobramycin)
MULTI
HEALTHNET_OR-HNOR-TOBRAMYCIN-BETHKIS-KITABIS-PAK-TOBI-TOBI-PODHALER-CP-PHA-00DB58EEA2, Tobramycin (Bethkis, Kitabis Pak, TOBI, TOBI Podhaler); CP.PHAR.211
OR
EVICORE-MEDICAL_DRUG-0CF1C91F93F8
Related Codes
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