J9281, Mitomycin pyelocalyceal instillation, 1 mg
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
- Procedure codes listed are for general reference and may not be all-inclusive.
- Benefit coverage/reimbursement determinations must be based on the written coverage position in the Medical Policy, not on the presence or absence of listed codes.
- Coverage determinations must include review of the member's benefit contract or SPD for coverage definitions, exclusions, and limitations (e.g., dollar or duration caps).
Key Coverage Criteria
- Medically necessary when the drug is FDA‑approved and administered in accordance with FDA labeling for an oncologic indication.
- Medically necessary when the drug has an NCCN category 1, 2A, or 2B recommendation or is listed in the NCCN Drugs & Biologics Compendium.
- Medically necessary when the drug is FDA‑approved and administered in accordance with FDA labeling for an oncologic indication.
- Medically necessary when the drug has an NCCN category 1, 2A, or 2B recommendation or is listed in the NCCN Drugs & Biologics Compendium.
- Oncology medications are medically necessary if (a) the drug is FDA-approved for the oncologic indication and used per FDA labeling, OR (b) the drug has an NCCN Category 1/2A/2B indication per NCCN Guidelines or NCCN Compendium.
- Oncology medications may be considered medically necessary when the drug (a) is FDA-approved for an oncologic indication and used per FDA labeling, or (b) has NCCN Category 1/2A/2B recommendation per NCCN Guidelines or NCCN Compendium.
12 Active Policies
BCBSIL-RX502.061, Oncology Medications
BCBSMT-RX502.061, Oncology Medications
BCBSNM-RX502.061, Oncology Medications
BCBSOK-RX502.061, Oncology Medications
EVICORE-HPLAN-CIGNA-91DEEEDD92F8, Cigna MedOnc Master Drug List
Related Codes
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