Q5122, Injection, pegfilgrastim-apgf (nyvepria), biosimilar, 0.5 mg
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high confidence)
Medicare Pricing
Documentation Required
- This article provides billing and coding guidelines that complement Local Coverage Determination (LCD) L37176 for White Cell Colony Stimulating Factors; refer to LCD L37176 for specific coverage criteria, indications, and limitations.
- Documentation of a prior, medically necessary allogeneic bone marrow transplantation or peripheral stem cell transplantation (e.g., transplant operative report, discharge summary, transplant center records).
- Clinical documentation supporting the indication for DLI (diagnosis/problem list with corresponding ICD-10 code among covered diagnoses such as C91.00-C91.02, C92.00-C92.02, C92.10-C92.12, or documentation of transplant status Z94.81 / Z94.84).
- Medical records demonstrating that the requested DLI is not one of the policy-listed experimental/investigational uses (e.g., not CAR-modified donor lymphocytes, not G-CSF-stimulated DLI for the purpose stated, not intrathecal DLI, not ECP-treated donor cells for pre-transplant organ tolerance, etc.).
- If applicable, documentation of prior treatments and rationale for DLI as salvage therapy or for graft-versus-leukemia effects (e.g., prior relapse after allo-HCT, prior therapies tried and outcomes).
- Coding/billing documentation aligning with the covered CPT/HCPCS/ICD-10 codes listed in the policy when selection criteria are met.
Key Coverage Criteria
- Medically necessary use of Leukine, Neupogen, Nivestym, Nypozi, Releuko, and Zarxio for bone marrow/stem cell transplant indications when: (a) non-myeloid malignancies with myeloablative chemotherapy followed by BMT; or (b) mobilization of hematopoietic progenitor cells into peripheral blood for leukapheresis; or (c) PSCT after myeloablative chemotherapy.
- ICD-10 codes covered if selection criteria are met: Z94.84 (Stem cells transplant status).
- ICD-10 codes covered if selection criteria are met: C92.10 - C92.12 (Chronic myeloid leukemia, BCR/ABL-positive).
- ICD-10 codes covered if selection criteria are met: Z94.81 (Bone marrow transplant status).
- Donor lymphocyte infusion (DLI) is considered medically necessary for persons who have a prior, medically necessary allogeneic bone marrow or peripheral stem cell transplantation.
- DLI for treatment/management related to the following covered ICD-10 diagnoses when selection criteria are met: C91.00 - C91.02 (Acute lymphoblastic leukemia [ALL]).
18 Active Policies
A56748, Billing and Coding: White Cell Colony Stimulating Factors
UHC-POL-white-blood-cell-colony-stimulating-factors, White Blood Cell Colony Stimulating Factors
AETNA-CPB-0638, Donor Lymphocyte Infusion
BCBSIL-RX502.061, Oncology Medications
BCBSMT-RX502.061, Oncology Medications
BCBSNM-RX502.061, Oncology Medications
BCBSOK-RX502.061, Oncology Medications
CARELON-febrile-neutropenia-risk, Febrile Neutropenia Risk
UMR-POL-UMR-white-blood-cell-colony-stimulating-factors, White Blood Cell Colony Stimulating Factors
SUREST-POL-SUREST-white-blood-cell-colony-stimulating-factors, White Blood Cell Colony Stimulating Factors
EVICORE-HPLAN-CIGNA-91DEEEDD92F8, Cigna MedOnc Master Drug List
EVICORE-HPLAN-CIGNA_MEDICARE-F57DF6FC9C3C, Q1 - 2025 1199 SEIU Benefit Funds MedOnc Master Drug List
EVICORE-HPLAN-CIGNA_MEDICARE-6408D93491D1, Q1 - 2026 1199 SEIU Benefit Funds MedOnc Master Drug List
EVICORE-HPLAN-CIGNA_MEDICARE-65E4ECCF1ADE, Q2 - 2025 1199 SEIU Benefit Funds MedOnc Master Drug List
EVICORE-HPLAN-CIGNA_MEDICARE-A5899B49CF60, Q2 - 2026 1199 SEIU Benefit Funds MedOnc Master Drug List
EVICORE-HPLAN-CIGNA_MEDICARE-C882D62DFEB4, Q3 - 2025 1199 SEIU Benefit Funds MedOnc Master Drug List
EVICORE-HPLAN-CIGNA_MEDICARE-44F27329FED1, Q4 - 2025 1199 SEIU Benefit Funds MedOnc Master Drug List
EVICORE-HPLAN-HEALTH_PARTNERS_PLANS-1D3B8C21C093, Q2 - 2026 Health Partners Plans MedOnc Master Drug List
Related Codes
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