Q5130 — Injection, pegfilgrastim-pbbk (fylnetra), biosimilar, 0.5 mg
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
- 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.
- Medical record must document medical necessity of services performed for each date of service submitted on a claim; documentation must be available to the A/B MAC upon request.
- When used for primary or secondary prophylaxis with cancer therapy, the record must document risk factors in patients receiving agents/doses uncommonly associated with myelosuppression.
- For treatment of covered chronic neutropenia, the medical record must document appropriate evaluation of the cause of neutropenia and where appropriate, a history of recurrent fevers and/or infections.
Key Coverage Criteria
- - Adult AML shortly after completion of induction or repeat induction chemotherapy, or after consolidation chemotherapy for AML.
- - Treatment of severe neutropenia in hairy cell leukemia.
- - MDS with severe neutropenia (ANC ≤ 500/mm3) or recurrent infection.
- Filgrastim (Neupogen®) and filgrastim-sndz (Zarxio®): indicated uses above apply to the biosimilar as approved for Neupogen's indications.
- Filgrastim (Neupogen®): for chronic administration in symptomatic patients with severe chronic neutropenia (congenital neutropenia, cyclic neutropenia, idiopathic neutropenia) to reduce incidence and duration of neutropenia sequelae.
- Enhancement of recovery of blood-related functions in neutropenia, including febrile neutropenia (FN).
5 Active Policies
A56748 — Billing and Coding: White Cell Colony Stimulating Factors
L37176 — White Cell Colony Stimulating Factors
UHC-POL-white-blood-cell-colony-stimulating-factors — White Blood Cell Colony Stimulating Factors
UMR-POL-UMR-white-blood-cell-colony-stimulating-factors — White Blood Cell Colony Stimulating Factors
SUREST-POL-SUREST-white-blood-cell-colony-stimulating-factors
Related Codes
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