Q5136, Injection, denosumab-bbdz (jubbonti/wyost), biosimilar, 1 mg
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high confidence)
Medicare Pricing
Documentation Required
- For management of hypercalcemia of malignancy document ICD-10-CM code E83.52, the related malignancy, and the rationale for denosumab use.
- Medical record must contain documentation that fully supports the medical necessity for administration of the specific denosumab formulation used.
- For postmenopausal osteoporosis include menopausal status (female), age and sex, documentation supporting the osteoporosis diagnosis, prior osteoporosis treatments and outcomes/adverse reactions, prior fracture history (type, cause, time), and fracture risk factors/preventive measures.
- For CTIBL include documentation of breast cancer or nonmetastatic prostate cancer, use of adjuvant AI or ADT, and any additional diagnosed risk factors.
- For treatment of bone metastasis document the related malignancy, the clinical rationale for denosumab use, and confirmation that the patient is adequately supplemented with calcium and vitamin D.
- Use the appropriate HCPCS code for the specific denosumab product on Part A and Part B claims: J0897 for Prolia®/Xgeva®; Q5136 for Jubbonti®/Wyost®; Q5157 for denosumab-bmwo (Stoboclo®, Osenvelt®); Q5158 for denosumab-bnht (Bomyntra®, Conexxence®); Q5159 for denosumab-dssb (Ospomyv™, Xbryk™).
Key Coverage Criteria
- Denosumab is covered for postmenopausal osteoporosis in patients at high risk for fracture when medical record documents menopausal status, diagnosis of osteoporosis, prior osteoporosis treatments and outcomes, fracture history, and fracture risk factors.
- Denosumab is covered for cancer treatment–induced bone loss (CTIBL) in patients with breast cancer receiving adjuvant aromatase inhibitors (AI) or in patients with nonmetastatic prostate cancer receiving androgen deprivation therapy (ADT) when documentation supports the cancer diagnosis and therapy.
- Denosumab is covered for treatment of bone metastasis from a solid tumor when the claim lists bone metastasis (ICD-10-CM C79.51) as the primary diagnosis and the original cancer or history of cancer is included as the secondary diagnosis.
- Denosumab is covered for management of hypercalcemia of malignancy when ICD-10-CM code E83.52 and the related malignancy and clinical rationale are documented.
- Denosumab (Xgeva®) is covered for treatment of skeletal-related events in patients with multiple myeloma per FDA approval effective 01/04/2018 when clinical rationale is documented.
- Coverage requires that the patient be adequately supplemented with calcium (1000 mg daily) and vitamin D (at least 400 IU daily) and that hypocalcemia be corrected prior to initiation of denosumab.
20 Active Policies
A52399, Billing and Coding: Denosumab (Prolia, Xgeva, Jubbonti, Wyost, Ospomyv,Xbryk,Bomyntra, Conexxence, Stoboclo, Osenvelt,Bildyos, Bilprevda)
J6
NGS-L33394, Drugs and Biologicals, Coverage of, for Label and Off-Label Uses
JK
UHC-POL-oncology-medication-clinical-coverage-policy, Oncology Medication Clinical Coverage
UHC-POL-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care
BCBSIL-RX501.140, Denosumab and Biosimilars for Non-Oncologic Indications
BCBSMT-RX501.140, Denosumab and Biosimilars for Non-Oncologic Indications
BCBSNM-RX501.140, Denosumab and Biosimilars for Non-Oncologic Indications
BCBSOK-RX501.140, Denosumab and Biosimilars for Non-Oncologic Indications
UMR-POL-UMR-denosumab-prolia-xgeva, Denosumab
UMR-POL-UMR-oncology-medication-clinical-coverage-policy, Oncology Medication Clinical Coverage
UMR-POL-UMR-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care
SUREST-POL-SUREST-denosumab-prolia-xgeva, Denosumab
SUREST-POL-SUREST-oncology-medication-clinical-coverage-policy, Oncology Medication Clinical Coverage
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
Related Codes
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