J3489, Injection, zoledronic acid, 1 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
- If bone metastasis (C79.51 or C79.52) is treated, the medical record must also contain the diagnosis of the primary malignant neoplasm and be available on request.
- Medical records must include diagnostic information and lab results that support medical necessity, including documentation of specific signs and symptoms substantiating FDA labeled or off‑label use.
- The record should indicate the patient was advised to take adequate calcium and vitamin D supplementation.
- Diagnosis codes supporting medical necessity must be submitted on the claim, including breast cancer code plus bone loss code and a code documenting current adjuvant SERM or aromatase inhibitor therapy when applicable.
Key Coverage Criteria
- Intravenous bisphosphonate administration is covered for treatment of osteoporosis when medical record documents need for IV route, including description of treatment failure of oral or self‑administered osteoporosis drugs.
- Bisphosphonate therapy is covered for heterotopic ossification when the medical record documents clinical need for treatment and justifies IV administration.
- Bisphosphonate therapy is covered for bone metastasis (C79.51 or C79.52) provided the patient's record also contains a diagnosis of the primary malignant neoplasm.
- In breast cancer patients receiving adjuvant selective estrogen receptor modulators or aromatase inhibitor therapy, bisphosphonates are covered when billed with an appropriate breast cancer diagnosis code and a bone loss diagnosis code documenting treatment indication.
- “When bilateral core decompression is indicated, it can be done simultaneously on both hips...”
- Aetna considers core decompression medically necessary for the treatment of early/pre-collapse (stage I or II; before X-ray changes are evident) avascular necrosis of the hip (femoral head and/or neck).
10 Active Policies
A56907, Billing and Coding: Bisphosphonate Drug Therapy
J5
WPS-L34648, Bisphosphonate Drug Therapy
J8
EVICORE-HPLAN-CIGNA_MEDICARE-F57DF6FC9C3C, Q1 - 2025 1199 SEIU Benefit Funds MedOnc Master Drug List
EVICORE-HPLAN-CIGNA_MEDICARE-6408D93491D1, Q1 - 2026 1199 SEIU Benefit Funds MedOnc Master Drug List
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.