J7527 — Everolimus, oral, 0.25 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
- A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted, and for DMEPOS base items requiring WOPD the supplier must have a signed WOPD prior to delivery.
- Suppliers must maintain proof of delivery (POD) documentation in their files and produce POD upon request by the Medicare contractor.
- For refills of DMEPOS items and supplies, suppliers must contact the beneficiary and document an affirmative response prior to dispensing the refill, and this contact must occur no sooner than 30 calendar days prior to the expected end of the current supply.
- For delivery of refills, suppliers must document that delivery occurs no sooner than 10 calendar days prior to the expected end of the current supply.
Key Coverage Criteria
- Immunosuppressive drugs are covered when FDA-approved and the approved labeling includes an indication for preventing or treating rejection of a transplanted organ or tissue.
- Immunosuppressive drugs are covered when FDA-approved and the labeling indicates use in conjunction with immunosuppressive drugs to prevent or treat transplant rejection.
- Immunosuppressive drugs are covered when FDA-approved and the DME MAC, in processing a Medicare claim, determines the drug is reasonable and necessary to prevent or treat rejection or to be used in conjunction with such drugs.
- Compounded formulations derived solely from FDA-approved immunosuppressive drugs are covered when administered orally or enterally.
- Dosage, frequency, and route of administration must conform to generally accepted medical practice and be medically necessary to prevent or treat organ transplant rejection.
- Drugs that meet the above criteria are covered irrespective of whether they can be self-administered, subject to other policy limitations.
1 Active Policy
L33824 — Immunosuppressive Drugs
J19
Related Codes
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