Does J9172 require prior authorization?

Yes, J9172 requires prior authorization (high confidence). Code explicitly requires prior authorization.

What is the Medicare reimbursement rate for J9172?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

HCPCS/CPT

Prior Auth Required

Code explicitly requires prior authorization (high confidence)

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Coverage of injectable oncology medications is based on NCCN Compendium Categories of Evidence and Consensus (1, 2A, 2B = proven/medically necessary; 3 = unproven/not medically necessary); if NCCN is unavailable, base decisions on FDA labeling.
Coverage is provided for injectable oncology medications listed in the NCCN Compendium with Categories of Evidence and Consensus of 1, 2A, or 2B as proven and medically necessary; categories with 3 are unproven and not medically necessary.
Coverage is provided for injectable oncology medications listed in the NCCN Compendium with Categories of Evidence and Consensus of 1, 2A, or 2B as proven and medically necessary; Category 3 is unproven and not medically necessary. If NCCN has no compendium, coverage determinations are based on FDA labeling.

UHC-POL-oncology-medication-clinical-coverage-policy, Oncology Medication Clinical Coverage

UMR-POL-UMR-oncology-medication-clinical-coverage-policy, Oncology Medication Clinical Coverage

SUREST-POL-SUREST-oncology-medication-clinical-coverage-policy, Oncology Medication Clinical Coverage

EVICORE-HPLAN-CIGNA-91DEEEDD92F8, Cigna MedOnc Master Drug List

Ask Verity about documentation requirements, denial risks, or coverage in your state.