Q5161, Injection, denosumab-kyqq (aukelso/bosaya), biosimilar, 1 mg
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high confidence)
Documentation Required
- 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).
- Authorization is for no more than 12 months
Key Coverage Criteria
- Initiation of denosumab (for glucocorticoid-induced osteoporosis) requires: diagnosis of glucocorticoid-induced osteoporosis; high fracture risk; dosing per FDA labeling; authorization for up to 12 months. Reauthorization requires positive clinical response, FDA-label dosing, and up to 12 months.
- 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.
- Denosumab (Prolia®) and its biosimilars are medically necessary for postmenopausal osteoporosis with history of fragility fractures OR T-score ≤ -2.5 and high fracture risk; or osteoporosis in men with history of fragility fractures OR T-score ≤ -2.5 and high risk; or glucocorticoid-induced osteoporosis with T-score ≤ -2.5 or fragility fracture AND ongoing prednisone ≥5 mg/day for ≥6 months.
- 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.
14 Active Policies
UHC-POL-denosumab-prolia-xgeva, Denosumab
BCBSIL-RX501.140, Denosumab and Biosimilars for Non-Oncologic Indications
BCBSIL-RX502.061, Oncology Medications
BCBSMT-RX501.140, Denosumab and Biosimilars for Non-Oncologic Indications
BCBSMT-RX502.061, Oncology Medications
Related Codes
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