J9215, Injection, interferon, alfa-n3, (human leukocyte derived), 250,000 iu
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
- Claims must be supported by medical record documentation of the patient’s diagnosis/clinical condition and justification that the selected drug, dose, and route of administration are appropriate and medically necessary for the non-oncologic indication.
- Billing must comply with Medicare rules and any applicable LCD prior authorization or documentation requirements; follow any specific forms or prior authorization processes required by the LCD or payer.
- Documentation that the keloid scar is painful, ulcerated, or pruritic and that it causes a functional impairment (example given: restricted movement) is required for coverage of keloid-specific procedures (explicitly stated in bracketed clarification for CPT 17110/17111).
- Documentation that selection criteria for the CPB are met (selection criteria themselves are referenced but not included in this document chunk).
Key Coverage Criteria
- Anti-neoplastic (chemotherapy) agent CPT/HCPCS codes may be used to bill for administration of these drugs when given to treat non-oncologic (noncancer) diagnoses if the drug is medically necessary for the patient’s condition and consistent with the standard of medical practice.
- Monoclonal antibody agents and other biologic response modifiers may be administered and billed using chemotherapy administration codes for noncancer indications when the dose, route, and clinical use are appropriate and medically necessary.
- Treatment of traumatic or surgical scars with non-ablative fractional laser (NAFL, 1,500-nm) or ablative fractional laser (AFL, 10,600-nm) — Chitgopeker et al, 2020 (split-scar study in 100 patients)
- Ablative fractional lasers (CO2 10,600-nm and Er:YAG 2,940-nm) to improve erythema, height, and pliability of hypertrophic and keloid scars — Oosterhoff et al, 2021 systematic review
- 1,470-nm diode laser with an intralesional optical fiber device for treatment of inflamed keloid scars accompanying serious local infection and fester — Li et al, 2019
- Micro-plasma radiofrequency (MPR) combined with hypo-fractionated electron-beam radiation (EBR) for treatment of multiple/widely distributed keloids — Zhang et al, 2019 (case series)
4 Active Policies
A55639, Billing and Coding: Chemotherapy Agents for Non-Oncologic Conditions
J5
WPS-L37205, Chemotherapy Drugs and their Adjuncts
J8
AETNA-CPB-0389, Hypertrophic Scars and Keloids
AETNA-CPB-0759, Vulvodynia and Vulvar Vestibulitis Treatments
Related Codes
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