Q5130, Injection, pegfilgrastim-pbbk (fylnetra), biosimilar, 0.5 mg
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires 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.
- Procedure codes listed are for general reference and may not be all-inclusive.
- Benefit coverage/reimbursement determinations must be based on the written coverage position in the Medical Policy, not on the presence or absence of listed codes.
- Coverage determinations must include review of the member's benefit contract or SPD for coverage definitions, exclusions, and limitations (e.g., dollar or duration caps).
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.
- Medically necessary when the drug is FDA‑approved and administered in accordance with FDA labeling for an oncologic indication.
- Medically necessary when the drug has an NCCN category 1, 2A, or 2B recommendation or is listed in the NCCN Drugs & Biologics Compendium.
- Medically necessary when the drug is FDA‑approved and administered in accordance with FDA labeling for an oncologic indication.
- Medically necessary when the drug has an NCCN category 1, 2A, or 2B recommendation or is listed in the NCCN Drugs & Biologics Compendium.
- Oncology medications are medically necessary if (a) the drug is FDA-approved for the oncologic indication and used per FDA labeling, OR (b) the drug has an NCCN Category 1/2A/2B indication per NCCN Guidelines or NCCN Compendium.
16 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
BCBSIL-RX502.061, Oncology Medications
BCBSMT-RX502.061, Oncology Medications
BCBSNM-RX502.061, Oncology Medications
Related Codes
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