Billing and Coding: Denosumab (Prolia®, Xgeva®, Jubbonti®, Wyost®, Ospomyv™,Xbryk™,Bomyntra®, Conexxence®, Stoboclo®, Osenvelt®)

Denosumab is covered for postmenopausal osteoporosis at high fracture risk, cancer treatment–induced bone loss in patients on AI or ADT, treatment of bone metastases from solid tumors (primary diagnosis C79.51), management of hypercalcemia of malignancy (E83.52), and for skeletal-related events in multiple myeloma per FDA approval. Coverage requires correction of hypocalcemia and adequate calcium (1000 mg daily) and vitamin D (≥400 IU daily) supplementation, proper HCPCS coding per formulation, and dosing consistent with the FDA label or recognized compendia; services outside labeled/compendia parameters may be reviewed or denied.

"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 ..."

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