J8499, Prescription drug, oral, non chemotherapeutic, nos
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high confidence)
Medicare Pricing
Documentation Required
- Signed and dated office visit records and operative reports are required; all services ordered or rendered to Medicare beneficiaries must be signed.
- For services requiring a referring/ordering physician, the referring/ordering physician's name and NPI must be reported on the claim.
- The patient's medical record must include the ordering provider's assessment related to the patient's complaint for that visit and relevant medical history.
- Document results of pertinent tests/procedures; for diagnostic tests report the test result if known, otherwise report the symptoms that prompted the test.
- When using modifier -GA, an ABN (Form CMS-R-131) should be signed by the beneficiary to indicate acceptance of payment responsibility, and for claims submitted to the Part A MAC occurrence code 32 and the date of the ABN are required.
- Providers should review NCCI and OPPS requirements prior to billing as procedure codes may be subject to NCCI edits or OPPS packaging edits.
Key Coverage Criteria
- Chelation therapy is covered as medically necessary for heavy metal toxicity and overload conditions (e.g., iron, copper, lead, aluminum).
- Sublingual immunotherapy with Oralair, Grastek, or Ragwitek is medically necessary for pollen-induced allergic rhinitis/rhinoconjunctivitis when used per FDA labeling and the patient has a history of rhinitis/rhinoconjunctivitis symptoms related to grass or short ragweed pollen exposure.
- Sublingual immunotherapy with Oralair, Grastek, or Ragwitek is medically necessary for pollen-induced allergic rhinitis/rhinoconjunctivitis when there is a history of grass or short ragweed pollen–related symptoms, per FDA labeling.
- Medically necessary SLIT with Oralair, Grastek, or Ragwitek for pollen-induced allergic rhinitis/rhinoconjunctivitis when: 1) there is a history of rhinitis/rhinoconjunctivitis symptoms related to grass or short ragweed pollen exposure; and 2) the product is used per FDA labeling.
- Medically necessary Odactra for house dust mite–induced allergic rhinitis/rhinoconjunctivitis when: 1) history of rhinitis/rhinoconjunctivitis symptoms related to dust mite exposure; 2) positive HDM-specific skin test or HDM-specific IgE; 3) symptoms not adequately controlled by pharmacotherapy.
- Chelation therapy for heavy metal toxicity and overload conditions (e.g., Iron, Copper, Lead, Aluminum) is proven and medically necessary.
16 Active Policies
CGS-L38268, Immune Thrombocytopenia (ITP) Therapy
J15
UHC-POL-chelation-therapy-non-overload-conditions, Chelation Therapy
BCBSIL-MED206.006, Sublingual Immunotherapy as a Technique of Allergen-Specific Therapy
BCBSMT-MED206.006, Sublingual Immunotherapy as a Technique of Allergen-Specific Therapy
BCBSNM-MED206.006, Sublingual Immunotherapy as a Technique of Allergen-Specific Therapy
BCBSOK-MED206.006, Sublingual Immunotherapy as a Technique of Allergen-Specific Therapy
UMR-POL-UMR-chelation-therapy-non-overload-conditions, Chelation Therapy
SUREST-POL-SUREST-chelation-therapy-non-overload-conditions, Chelation Therapy
EVICORE-HPLAN-CIGNA-91DEEEDD92F8, Cigna MedOnc Master Drug List
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
EVICORE-HPLAN-CIGNA_MEDICARE-65E4ECCF1ADE, Q2 - 2025 1199 SEIU Benefit Funds MedOnc Master Drug List
EVICORE-HPLAN-CIGNA_MEDICARE-A5899B49CF60, Q2 - 2026 1199 SEIU Benefit Funds MedOnc Master Drug List
EVICORE-HPLAN-CIGNA_MEDICARE-C882D62DFEB4, Q3 - 2025 1199 SEIU Benefit Funds MedOnc Master Drug List
A57160, Billing and Coding: Immune Thrombocytopenia (ITP) Therapy
EVICORE-HPLAN-CIGNA_MEDICARE-44F27329FED1, Q4 - 2025 1199 SEIU Benefit Funds MedOnc Master Drug List
Related Codes
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