J9311 — Injection, rituximab 10 mg and hyaluronidase
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
- Refer to Local Coverage Determination L35026 for clinical coverage criteria, medical necessity requirements, and any required prior authorization; this article complements that LCD with billing/coding guidance.
- The provided policy text does not specify required documentation (e.g., prior authorization forms, specific tests); documentation requirements for coverage (especially for off-label uses) should be confirmed with the A/B MAC.
- Physician attestation is required when requesting a non-preferred product: physician must attest that the same intolerance, contraindication, or adverse event would not be expected to occur with the respective non-preferred product.
- Coverage determinations must reference NCCN Drugs & Biologics Compendium listings and the Categories of Evidence and Consensus (1, 2A, 2B supported as medically necessary; Category 3 not medically necessary) as the evidentiary basis.
Key Coverage Criteria
- Rituximab is covered as a single agent for relapsed or refractory, low-grade or follicular, CD20-positive B-cell non-Hodgkin lymphoma (NHL).
- Rituximab is covered in previously untreated follicular, CD20-positive B-cell NHL in combination with first-line chemotherapy and, for patients achieving a complete or partial response, as single-agent maintenance therapy.
- Rituximab is covered as a single agent for non-progressing (including stable disease), low-grade, CD20-positive B-cell NHL after first-line cyclophosphamide, vincristine and prednisone (CVP) chemotherapy.
- Rituximab is covered in previously untreated diffuse large B-cell, CD20-positive NHL in combination with CHOP or other anthracycline-based chemotherapy regimens.
- Rituximab in combination with fludarabine and cyclophosphamide (FC) is covered for the treatment of previously untreated and previously treated CD20-positive chronic lymphocytic leukemia (CLL).
- Rituximab with methotrexate is covered for adult patients (age >=18) with moderately to severely active rheumatoid arthritis (RA) who have had an inadequate response to one or more tumor necrosis factor (TNF) antagonist therapies.
8 Active Policies
A56380 — Billing and Coding: Rituximab
L35026 — Rituximab
UHC-POL-oncology-medication-clinical-coverage-policy — Oncology Medication Clinical Coverage
UHC-POL-rituxan-rituximab — Rituximab (Riabni, Rituxan, Ruxience, & Truxima)
UMR-POL-UMR-oncology-medication-clinical-coverage-policy — Oncology Medication Clinical Coverage
Related Codes
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