J8540, Dexamethasone, 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; lack of a completed SWO will result in denial.
- For DMEPOS base items requiring WOPD, the supplier must have a signed WOPD prior to delivery; WOPD must list the base item and may list separately billed associated options/accessories/supplies.
- Suppliers are required to maintain proof of delivery (POD) documentation and make it available to the Medicare contractor upon request.
- Suppliers must contact the beneficiary for DMEPOS refills and document an affirmative response prior to dispensing refills; contact must occur no sooner than 30 calendar days prior to expected end of current supply.
Key Coverage Criteria
- Coverage requires that the item meet Medicare statutory criteria (eligible benefit category and be reasonable and necessary) per Social Security Act §1862(a)(1)(A).
- An FDA‑approved oral 3‑drug antiemetic regimen consisting of an oral NK‑1 antagonist plus an oral 5‑HT3 antagonist and dexamethasone (HCPCS J8540) is covered when administered to beneficiaries receiving one or more of the following chemotherapeutic agents: Alemtuzumab, Azacitidine, Bendamustine, Carboplatin, Carmustine, Cisplatin, Clofarabine, Cyclophosphamide, Cytarabine, Dacarbazine, Daunorubicin, Doxorubicin, Epirubicin, Idarubicin, Ifosfamide, Irinotecan, Lomustine, Mechlorethamine, Oxalipla [...]
- Laser trabeculoplasty for treatment of members with refractory primary open-angle glaucoma (POAG) when first-line drugs (e.g., latanoprost or timolol) and second-line drugs (e.g., brimonidine or dorzolamide) have failed to control intra-ocular pressure (IOP).
- FDA‑approved aqueous drainage/shunt implants for treatment of members with refractory primary open‑angle glaucoma when first-line and second-line drugs have failed to control IOP. (Examples listed in policy: Ahmed glaucoma implant; Baerveldt seton; Ex‑PRESS mini glaucoma shunt; Glaucoma pressure regulator; Krupin‑Denver valve implant; Molteno implant; Schocket shunt.)
- Ab interno Kahook Dual Blade trabeculectomy — described as used for primary congenital glaucoma in case reports (Harvey and Schmitz 2020) and discussed as a minimally invasive technique.
- Ab interno supraciliary microstent surgery (e.g., CyPass) — RCT evidence showed superiority combined with phacoemulsification vs phaco alone at 24 months, but long-term safety concerns (endothelial cell loss) led to device withdrawal (Cochrane review summary).
3 Active Policies
L33827, Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics)
AETNA-CPB-0484, Glaucoma Surgery
AETNA-CPB-0422, Vitiligo
Related Codes
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