Q0177, Hydroxyzine pamoate, 25 mg, oral, fda approved prescription anti-emetic, for
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
- A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted; lack of a completed SWO will result in denial.
- For DMEPOS base items requiring WOPD, the supplier must have a signed WOPD prior to delivery; WOPD must list the base item and may list separately billed associated options/accessories/supplies.
- Suppliers are required to maintain proof of delivery (POD) documentation and make it available to the Medicare contractor upon request.
- Suppliers must contact the beneficiary for DMEPOS refills and document an affirmative response prior to dispensing refills; contact must occur no sooner than 30 calendar days prior to expected end of current supply.
Key Coverage Criteria
- Coverage requires that the item meet Medicare statutory criteria (eligible benefit category and be reasonable and necessary) per Social Security Act §1862(a)(1)(A).
- An FDA‑approved oral 3‑drug antiemetic regimen consisting of an oral NK‑1 antagonist plus an oral 5‑HT3 antagonist and dexamethasone (HCPCS J8540) is covered when administered to beneficiaries receiving one or more of the following chemotherapeutic agents: Alemtuzumab, Azacitidine, Bendamustine, Carboplatin, Carmustine, Cisplatin, Clofarabine, Cyclophosphamide, Cytarabine, Dacarbazine, Daunorubicin, Doxorubicin, Epirubicin, Idarubicin, Ifosfamide, Irinotecan, Lomustine, Mechlorethamine, Oxalipla [...]
1 Active Policy
L33827, Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics)
Related Codes
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