J9260 — Injection, methotrexate sodium, 50 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
- 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.
- Medical record must document the specific ICD-10 diagnosis being treated and link the diagnosis to an accepted compendia listing or FDA-approved indication for the drug.
- Documentation must show the drug's FDA approval status and indication or provide the specific compendia citation demonstrating acceptable support (NCCN category and Recommended Use; DrugDex class; AHFS/Clinical Pharmacology narrative; or Lexi-Drugs entry with evidence level).
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.
- Chemotherapy agents are covered when medically necessary, the drug is FDA-approved for the indication, and the drug is listed in the NCCN Clinical Practice Guidelines for the specific ICD-10 diagnosis being treated with an NCCN category 1 or 2A listing and used per the NCCN Recommended Use (order or combination).
- Chemotherapy agents are covered when medically necessary if the indication is listed in an alternative Medicare‑approved compendium at an accepted level: Micromedex DrugDex Class I, IIa, or IIb; AHFS narrative text 'supportive'; Clinical Pharmacology narrative text 'supportive'; or Lexi-Drugs listed as 'Use Off-Label' with evidence level A.
- The dose and route of administration must be appropriate for the patient's clinical condition and consistent with medical necessity and the standard of medical practice for the treated diagnosis.
- Extensive alopecia areata (involving more than 50 % loss of scalp hair) — treatments may include topical immunotherapy, systemic agents or other measures: "Therapy for extensive alopecia areata (involving more than 50 % loss of scalp hair) may be prolonged and difficult...Systemic corticosteroids are seldom used due to their adverse effects; however, they may be required depending on the severity of the condition and the adequacy of the response to topical therapy."
3 Active Policies
A55639 — Billing and Coding: Chemotherapy Agents for Non-Oncologic Conditions
J05
L37205 — Chemotherapy Drugs and their Adjuncts
J05
AETNA-CPB-0423 — Alopecia Areata
Related Codes
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