J8597, Antiemetic drug, oral, not otherwise specified
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
- A Standard Written Order (SWO) must be communicated to the supplier prior to claim submission for items requiring an SWO.
- For DMEPOS base items requiring a Written Order Prior to Delivery (WOPD), the supplier must have a signed WOPD listing the base item (and may list associated options/accessories) prior to delivery.
- Suppliers are required to maintain proof of delivery (POD) documentation in their files and make POD available to the Medicare contractor upon request.
- For refills, suppliers must contact the beneficiary and document an affirmative response prior to dispensing the refill and document the refill request; contact must occur no sooner than 30 days prior to expected end of current supply.
Key Coverage Criteria
- Oral anticancer drugs are covered when they are eligible for a defined Medicare benefit category, are reasonable and necessary for diagnosis or treatment (or to improve functioning of a malformed body member), and meet all applicable Medicare statutory and regulatory requirements.
- Coverage requires that the statutory coverage criteria for oral anticancer drugs, as specified in the related LCD Policy Article, are met and the drug must be reasonable and necessary for the individual beneficiary.
- Oral anticancer and oral antiemetic drugs are covered only if dispensed and billed to Medicare by the entity that actually dispenses the drug to the beneficiary and that entity is permitted under applicable federal, state, and local laws to dispense drugs.
8 Active Policies
L33826, Oral Anticancer Drugs
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
Related Codes
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