Does J2820 require prior authorization?

Yes, J2820 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for J2820?

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

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`J2820`, Injection, sargramostim (gm-csf), 50 mcg

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

This article provides billing and coding guidelines that complement Local Coverage Determination (LCD) L37176 for White Cell Colony Stimulating Factors; refer to LCD L37176 for specific coverage criteria, indications, and limitations.

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).

If chemotherapeutic regimen has a low or intermediate risk of febrile neutropenia (20% and less), documentation must be provided outlining the member’s risk factors that confirm the member is at high risk for febrile neutropenia.

Key Coverage Criteria

Medically necessary use of Leukine, Neupogen, Nivestym, Nypozi, Releuko, and Zarxio for bone marrow/stem cell transplant indications when: (a) non-myeloid malignancies with myeloablative chemotherapy followed by BMT; or (b) mobilization of hematopoietic progenitor cells into peripheral blood for leukapheresis; or (c) PSCT after myeloablative chemotherapy.
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.
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.
Oncology medications are medically necessary if (a) the drug is FDA-approved for the oncologic indication and used per FDA labeling, OR (b) the drug has an NCCN Category 1/2A/2B indication per NCCN Guidelines or NCCN Compendium.

17 Active Policies

PALMETTO-JJ-L37176, White Cell Colony Stimulating Factors

PALMETTO-JM-L37176, White Cell Colony Stimulating Factors

BCBSMS-L-5-01-453-357A13DE0E, Leukine (sargramostim)

BCBSMS-S-5-01-453-B1850CB4B9, State and School Employees' Health Insurance Plan - Leukine (sargramostim)

BCBSNJ-DRUGS-012-E7C32F18C6, Granulocyte Colony Stimulating Factor (G-CSF - Neupogen, Neulasta, Granix, Zarxio, Fulphila, Nivestym, Udenyca, Ziextenzo, Nyvepria) and Granulocyte-Macrophage Colony Stimulating Factor (GM-CSF - Leukine)

HEALTHNET_OR-HNOR-SARGRAMOSTIM-LEUKINE-CP-PHAR-295-58A214CC05, Sargramostim (Leukine); CP.PHAR.295

MODA-LEUKINE-17080D5A18, Leukine (sargramostim)

BCBSTN-89d8cb98ff, Sargramostim (Leukine)

UHC-POL-white-blood-cell-colony-stimulating-factors, White Blood Cell Colony Stimulating Factors

EVICORE-HPLAN-HEALTH_PARTNERS_PLANS-4BC80209CCC5, Q3 - 2026 Jefferson Health Plans MedOnc Master Drug List

SUREST-POL-SUREST-white-blood-cell-colony-stimulating-factors, White Blood Cell Colony Stimulating Factors

A56748, Billing and Coding: White Cell Colony Stimulating Factors

BCBSIL-RX502.061, Oncology Medications

BCBSMT-RX502.061, Oncology Medications

BCBSNM-RX502.061, Oncology Medications

BCBSOK-RX502.061, Oncology Medications

UMR-POL-UMR-white-blood-cell-colony-stimulating-factors, White Blood Cell Colony Stimulating Factors

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J2820, Injection, sargramostim (gm-csf), 50 mcg