Does J1260 require prior authorization?

No, J1260 does not require prior authorization (high confidence). Covered without prior authorization.

What is the Medicare reimbursement rate for J1260?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`J1260`, Injection, dolasetron mesylate, 10 mg

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

For home infusion/home therapy codes (S9351, S9370): documentation of emetic risk category (high, moderate) when required and clinical justification for home-based administration (S9370 limited to high or moderate risk).
For Z51.0 and Z51.11 - Z51.12 when used for total body radiation: documentation that oral antiemetic therapy has failed or is contraindicated.

For all HCPCS/CPT codes listed as 'covered if selection criteria are met': documentation that the patient meets the CPB selection criteria (specific selection criteria and required documentation elements are referenced but not included in this excerpt).

For use in chemotherapy: documentation that the antiemetic regimen is being used for prevention of acute/delayed nausea and vomiting associated with initial or repeat courses of moderately or highly emetogenic chemotherapy, or that patient has inadequate response or contraindication to specified alternatives (e.g., failed oral granisetron or ondansetron for IV use).

Key Coverage Criteria

Prevention of acute nausea or vomiting associated with initial and repeat courses of moderately and highly emetogenic cancer chemotherapy, including high-dose cisplatin (palonosetron (Aloxi) or fosaprepitant dimeglumine (Emend)).
O21.0 - O21.9 — Excessive vomiting in pregnancy (when clinical signs of dehydration are present or nausea and vomiting have persisted more than 3 weeks and criteria A, B, and C are met)
B20 — Human immunodeficiency virus [HIV] disease
T45.1X5+ — Adverse effect of antineoplastic and immunosuppressive drugs (note: not covered for Anzemet per CPB)
Ondansetron or other 5-HT3 antagonists as pharmacologic options in refractory nausea and vomiting of pregnancy after first-line measures per ACOG; ondansetron may be tried in refractory cases as a last resort (ACOG-referenced).
Use of 5-HT3 receptor antagonists for management of postoperative nausea and vomiting and chemotherapy/radiotherapy-induced nausea and vomiting according to published guidelines (NCCN, ASCO, MASCC).

`J1260`, Injection, dolasetron mesylate, 10 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

1 Active Policy

Related Codes

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J1260, Injection, dolasetron mesylate, 10 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

1 Active Policy

Related Codes

Have a follow-up question?

`J1260`, Injection, dolasetron mesylate, 10 mg