J9263 — Injection, oxaliplatin, 0.5 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
- Clinical documentation confirming the specific diagnosis that matches one of the covered indications (e.g., pathology report, imaging, oncology consult).
- For adjuvant stage III colon cancer: documentation of complete resection of the primary tumor (operative and pathology reports) and staging consistent with stage III disease.
- For continuation of therapy: documentation demonstrating no disease progression and no unacceptable toxicity while on the current oxaliplatin regimen (treatment notes, imaging reports, toxicity assessments).
- Treatment plan including oxaliplatin dosing, schedule/regimen (e.g., FOLFOX dosing: oxaliplatin 85 mg/m2 IV over 120 minutes with leucovorin and 5-FU per label), number of cycles planned and number completed.
Key Coverage Criteria
- C18.0-C20 Malignant neoplasm of colon and rectum
- 96401-96450 Chemotherapy administration
- Gastric cancer.
- C44.500 Unspecified malignant neoplasm of anal skin [metastatic anal cancer]
- Biliary tract cancers, including intrahepatic and extrahepatic cholangiocarcinoma and gallbladder cancer.
- C25.0-C25.9 Malignant neoplasm of pancreas
1 Active Policy
AETNA-CPB-0683 — Oxaliplatin (Eloxatin)
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