J9999, Not otherwise classified, antineoplastic drugs
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Documentation Required
- Every Part A claim for NOC/unlisted drug, biologic, and radiopharmaceutical codes must include the appropriate NOC code and the appropriate diagnosis.
- Every claim must include the appropriate revenue codes for the drug and for IV infusion when applicable.
- Every claim must indicate the drug name, the National Drug Code (NDC) number, and the total dosage administered.
- For claim submission, the required documentation must be included in the remarks field (Field Locator 80) on the UB-04 (CMS 1450) or the equivalent 5010 electronic claim field.
- For Part B claims, follow the Palmetto GBA articles referenced on their website for additional required documentation specific to NOC drugs, biologics, and radiopharmaceuticals.
- For oncology NOC submissions prior to a unique HCPCS code, include the diagnosis code for the specific FDA label indication or, if no adequate diagnosis code exists, a specific narrative description of the indication.
Key Coverage Criteria
- For claims using not otherwise classified (NOC)/unlisted HCPCS codes J3490, J3590, J9999, A4641, or A9699 with limited or specific indications, submit required documentation in the claim remarks field (Field Locator 80 on the UB-04) or the equivalent 5010 electronic claim field so Palmetto GBA can ascertain FDA labeling indications have been met.
- For oncology drugs or oncology radiopharmaceuticals submitted with NOC codes prior to assignment of a unique HCPCS code, include the diagnosis code that corresponds to the specific FDA label indication or, if no adequate diagnosis code exists, include a specific narrative description of the indication (e.g., 'squamous cell carcinoma').
- Immune thrombocytopenic purpura (ITP) — treatment of ITP when all of the following are met: diagnosis of ITP; documented platelet count < 30 × 10^9/L; history of failure, contraindication, or intolerance to one of: Anti-D immunoglobulin, corticosteroids, immune globulin, thrombopoietin receptor agonist (TPO-RA) (e.g., eltrombopag, romiplostim), or splenectomy. (Initial authorization up to 12 months; reauthorization up to 12 months.)
- Pemphigus vulgaris — treatment of moderate to severe pemphigus vulgaris. (Initial authorization up to 12 months; reauthorization up to 12 months.)
- Wegener's granulomatosis (Granulomatosis with polyangiitis) or Microscopic polyangiitis — treatment when diagnosis is present and either patient is receiving concurrent glucocorticoids or has history of contraindication/intolerance to glucocorticoids. (Initial authorization up to 12 months; reauthorization up to 12 months.)
- Autoimmune hemolytic anemia (AIHA), including chronic cold agglutinin disease — treatment of AIHA. (Initial authorization up to 12 months; reauthorization up to 12 months.)
20 Active Policies
UHC-POL-rituxan-rituximab, Rituximab (Riabni, Rituxan, Ruxience, & Truxima)
AETNA-CPB-0245, Tumor Chemosensitivity Assays
MED203.002, Antineoplaston Cancer Therapy
RX501.140, Denosumab (Prolia & Xgeva) and Associated Biosimilars
RX501.066, Eculizumab and Associated Biosimilar(s)
BCBSIL-MED203.002, Antineoplaston Cancer Therapy
BCBSIL-RX501.140, Denosumab and Biosimilars for Non-Oncologic Indications
BCBSIL-RX501.066, Eculizumab and Associated Biosimilar(s)
BCBSIL-RX501.087, FDA - Drugs, Biologicals, Cellular and Gene Therapies
BCBSIL-RX504.003, Immunoglobulin Therapy
BCBSIL-RX502.061, Oncology Medications
BCBSMT-MED203.002, Antineoplaston Cancer Therapy
BCBSMT-RX501.140, Denosumab and Biosimilars for Non-Oncologic Indications
BCBSMT-RX501.066, Eculizumab and Associated Biosimilar(s)
BCBSMT-RX501.087, FDA - Drugs, Biologicals, Cellular and Gene Therapies
BCBSMT-RX504.003, Immunoglobulin Therapy
BCBSMT-RX502.061, Oncology Medications
BCBSNM-MED203.002, Antineoplaston Cancer Therapy
BCBSNM-RX501.140, Denosumab and Biosimilars for Non-Oncologic Indications
A54880, Billing and Coding: Additional Claim Documentation Requirements for Not Otherwise Classified (NOC) Drugs and Biological Products with Specific FDA Label Indications
Related Codes
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