Prior Authorization Changes to Oncology-related Codes

Code

Description

77436

SURFACE RADIATION THERAPY; SUPERFICIAL OR ORTHOVOLTAGE, TREATMENT PLANNING AND SIMULATION-AIDED FIELD SETTING

77437

SURFACE RADIATION THERAPY; SUPERFICIAL, DELIVERY, </=150 kV, PER FRACTION (e.g., ELECTRONIC BRACHYTHERAPY)

77438

SURFACE RADIATION THERAPY; ORTHOVOLTAGE, DELIVERY, >150-500 kV, PER FRACTION

77011

COMPUTED TOMOGRAPHY GUIDANCE FOR STEREOTACTIC LOCALIZATION

A9600

STRONTIUM SR-89 CHLORIDE, THERAPEUTIC, PER MILLICURIE

A9604

SAMARIUM SM-153 LEXIDRONAM, THERAPEUTIC, PER TREATMENT DOSE, UP TO 150 MILLICURIES

C9047

INJECTION, CAPLACIZUMAB-YHDP, 1 MG

C9293

INJECTION, GLUCARPIDASE, 10 UNITS

J0185

INJECTION, APREPITANT, 1 MG

J0207

INJECTION, AMIFOSTINE, 500 MG

J0208

INJECTION, SODIUM THIOSULFATE (PEDMARK), 100 MG

J0641

INJECTION, LEVOLEUCOVORIN, NOT OTHERWISE SPECIFIED, 0.5 MG

J0642

INJECTION, LEVOLEUCOVORIN (KHAPZORY), 0.5 MG

J0870

INJECTION, IMETELSTAT, 1 MG

J0881

INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)

J0885

INJECTION, EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS

J0888

INJECTION, EPOETIN BETA, 1 MCG, (FOR NON-ESRD USE)

J0893

INJECTION, DECITABINE (SUN PHARMA) NOT THERAPEUTICALLY EQUIVALENT TO J0894, 1 MG

J0894

INJECTION, DECITABINE, 1 MG

J1190

INJECTION, DEXRAZOXANE HYDROCHLORIDE, PER 250 MG

J1437

INJECTION, FERRIC DERISOMALTOSE, 10 MG

J1439

INJECTION, FERRIC CARBOXYMALTOSE, 1MG

J1454

INJECTION, FOSNETUPITANT 235 MG AND PALONOSETRON 0.25 MG

J1627

INJECTION, GRANISETRON, EXTENDED-RELEASE, 0.1 MG

J2277

INJECTION, MOTIXAFORTIDE, 0.25 MG

J2354

INJECTION, OCTREOTIDE, NONDEPOT FORM FOR SUBCUTANEOUS OR INTRAVENOUS INJECTION, 25 MCG

J2430

INJECTION, PAMIDRONATE DISODIUM, PER 30 MG

J2562

INJECTION, PLERIXAFOR, 1 MG

J2783

INJECTION, RASBURICASE, 0.5 MG

J2802

INJECTION, ROMIPLOSTIM, 1 MICROGRAM

J2916

INJECTION, SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE INJECTION, 12.5 MG

J3489

INJECTION, ZOLEDRONIC ACID, 1 MG

J9000

DOXORUBICIN HCL, 10 MG

J9015

INJECTION, ALDESLEUKIN, PER SINGLE USE VIAL

J9017

ARSENIC TRIOXIDE, 1MG

J9025

INJECTION, AZACITIDINE, 1 MG

J9027

INJECTION, CLOFARABINE, 1 MG

J9030

BCG LIVE INTRAVESICAL INSTILLATION, 1 MG

J9040

INJECTION, BLEOMYCIN SULFATE, 15 UNITS

J9043

INJECTION, CABAZITAXEL, 1 MG

J9045

INJECTION, CARBOPLATIN, 50 MG

J9050

INJECTION, CARMUSTINE, 100 MG

J9052

INJECTION, CARMUSTINE (ACCORD), NOT THERAPEUTICALLY EQUIVALENT TO J9050, 100 MG

J9060

INJECTION, CISPLATIN, POWDER OR S0LUTION, 10 MG

J9064

INJECTION, CABAZITAXEL (SANDOZ), NOT THERAPEUTICALLY EQUIVALENT TO J9043, 1 MG

J9071

INJECTION, CYCLOPHOSPHAMIDE, (AUROMEDICS), 5 MG

J9072

INJECTION, CYCLOPHOSPHAMIDE (AVYXA), 5 MG

J9073

INJECTION, CYCLOPHOSPHAMIDE (DR. REDDY S), 5 MG

J9074

INJECTION, CYCLOPHOSPHAMIDE (SANDOZ), 5 MG

J9075

INJECTION, CYCLOPHOSPHAMIDE, NOT OTHERWISE SPECIFIED, 5MG

J9076

INJECTION, CYCLOPHOSPHAMIDE (BAXTER), 5 MG

J9100

INJECTION, CYTARABINE, 100 MG.

J9130

DACARBAZINE, 100 MG

J9150

INJECTION, DAUNORUBICIN, 10 MG

J9153

INJECTION, LIPOSOMAL, 1 MG DAUNORUBICIN AND 2.27 MG CYTARABINE

J9155

INJECTION, DEGARELIX, 1 MG

J9171

INJECTION, DOCETAXEL, 1 MG

J9172

INJECTION, DOCETAXEL (DOCIVYX), 1 MG

J9174

INJECTION, DOCETAXEL (BEIZRAY), 1 MG

J9176

INJECTION, ELOTUZUMAB, 1 MG

J9179

INJECTION, ERIBULIN MESYLATE, 0.1 MG

J9181

INJECTION, ETOPOSIDE, 10 MG

J9184

INJECTION, GEMCITABINE HYDROCHLORIDE (AVYXA), 200 MG

J9185

INJECTION, FLUDARABINE PHOSPHATE, 50 MG

J9190

FLUOROURACIL, 500 MG

J9196

INJECTION, GEMCITABINE HYDROCHLORIDE (ACCORD), NOT THERAPEUTICALLY EQUIVALENT TO J9201, 200 MG

J9198

INJECTION, GEMCITABINE HYDROCHLORIDE, (INFUGEM), 100 MG

J9201

INJECTION, GEMCITABINE HYDROCHLORIDE, NOT OTHERWISE SPECIFIED, 200 MG

J9202

GOSERELIN ACETATE IMPLANT, PER 3.6 MG

J9203

INJECTION, GEMTUZUMAB OZOGAMICIN, 0.1 MG

J9204

INJECTION, MOGAMULIZUMAB-KPKC, 1 MG

J9206

INJECTION, IRINOTECAN, 20 MG

J9207

INJECTION, IXABEPILONE, 1 MG

J9208

INJECTION, IFOSFAMIDE, 1 GM

J9211

INJECTION, IDARUBICIN HYDROCHLORIDE, 5 MG

J9214

INJECTION, INTERFERON, ALFA-2B, RECOMBINANT, 1 MILLION UNITS

J9216

INTERFERON, GAMMA 1-B, 3 MILLION UNITS

J9223

INJECTION, LURBINECTEDIN, 0.1 MG

J9245

INJECTION, MELPHALAN HYDROCHLORIDE, NOT OTHERWISE SPECIFIED, 50 MG

J9249

INJECTION, MELPHALAN (APOTEX), 1 MG

J9263

INJECTION, OXALIPLATIN, 0.5 MG

J9264

INJECTION, PACLITAXEL PROTEIN-BOUND PARTICLES, 1 MG

J9267

INJECTION, PACLITAXEL, 1 MG

J9280

INJECTION, MITOMYCIN, 5 MG

J9281

MITOMYCIN PYELOCALYCEAL INSTILLATION, 1 MG

J9292

INJECTION, PEMETREXED DIPOTASSIUM, 10 MG

J9294

INJECTION, PEMETREXED (HOSPIRA), NOT THERAPEUTICALLY EQUIVALENT TO J9305, 10 MG

J9295

INJECTION, NECITUMUMAB, 1 MG

J9296

INJECTION, PEMETREXED (ACCORD), NOT THERAPEUTICALLY EQUIVALENT TO J9305, 10 MG

J9297

INJECTION, PEMETREXED (SANDOZ), NOT THERAPEUTICALLY EQUIVALENT TO J9305, 10 MG

J9302

INJECTION, OFATUMUMAB, 10 MG

J9304

INJECTION, PEMETREXED (PEMFEXY), 10 MG

J9305

INJECTION, PEMETREXED, NOT OTHERWISE SPECIFIED, 10 MG

J9314

INJECTION, PEMETREXED (TEVA), NOT THERAPEUTICALLY EQUIVALENT TO J9305, 10 MG

J9318

INJECTION, ROMIDEPSIN, NON-LYOPHILIZED, 0.1 MG

J9319

INJECTION, ROMIDEPSIN, LYOPHILIZED, 0.1 MG

J9322

INJECTION, PEMETREXED (BLUEPOINT), NOT THERAPEUTICALLY EQUIVALENT TO J9305, 10 MG

J9323

INJECTION, PEMETREXED DITROMETHAMINE, 10 MG

J9324

INJECTION, PEMETREXED (PEMRYDI RTU), 10 MG

J9325

INJECTION, TALIMOGENE LAHERPAREPVEC, PER 1 MILLION PLAQUE FORMING UNITS

J9328

INJECTION, TEMOZOLOMIDE, 1 MG

J9341

INJECTION, THIOTEPA (TEPYLUTE), 1 MG

J9342

INJECTION, THIOTEPA, NOT OTHERWISE SPECIFIED, 1 MG

J9348

INJECTION, NAXITAMAB-GQGK, 1 MG

J9351

INJECTION, TOPOTECAN, 0.1 MG

J9352

INJECTION, TRABECTEDIN, 0.1 MG

J9357

INJECTION, VALRUBICIN, INTRAVESICAL, 200 MG

J9360

VINBLASTINE SULFATE, 1 MG

J9370

VINCRISTINE SULFATE, 1 MG

J9390

VINORELBINE TARTRATE, PER 10 MG

J9400

INJECTION, ZIV-AFLIBERCEPT, 1 MG

J9600

INJECTION, PORFIMER SODIUM, 75 MG

Q0138

INJECTION, FERUMOXYTOL, FOR TREATMENT OF IRON DEFICIENCY ANEMIA, 1 MG (NON-ESRD USE)

Q2050

INJECTION, DOXORUBICIN HYDROCHLORIDE, LIPOSOMAL, NOT OTHERWISE SPECIFIED, 10MG

Q5106

INJECTION, EPOETIN ALFA-EPBX, BIOSIMILAR, (RETACRIT) (FOR NON-ESRD USE), 1000 UNITS