Does J7520 require prior authorization?

Yes, J7520 requires prior authorization (medium confidence). Conditional coverage; review criteria to confirm PA need.

What is the Medicare reimbursement rate for J7520?

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

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`J7520`, Sirolimus, oral, 1 mg

HCPCS/CPT

Prior Authorization

Prior Auth Required

Conditional coverage; review criteria to confirm PA need (medium confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted, and for DMEPOS base items requiring WOPD the supplier must have a signed WOPD prior to delivery.
Suppliers must maintain proof of delivery (POD) documentation in their files and produce POD upon request by the Medicare contractor.

For refills of DMEPOS items and supplies, suppliers must contact the beneficiary and document an affirmative response prior to dispensing the refill, and this contact must occur no sooner than 30 calendar days prior to the expected end of the current supply.

Key Coverage Criteria

Immunosuppressive drugs are covered when FDA-approved and the approved labeling includes an indication for preventing or treating rejection of a transplanted organ or tissue.
Immunosuppressive drugs are covered when FDA-approved and the labeling indicates use in conjunction with immunosuppressive drugs to prevent or treat transplant rejection.
Immunosuppressive drugs are covered when FDA-approved and the DME MAC, in processing a Medicare claim, determines the drug is reasonable and necessary to prevent or treat rejection or to be used in conjunction with such drugs.
Compounded formulations derived solely from FDA-approved immunosuppressive drugs are covered when administered orally or enterally.
Dosage, frequency, and route of administration must conform to generally accepted medical practice and be medically necessary to prevent or treat organ transplant rejection.
Drugs that meet the above criteria are covered irrespective of whether they can be self-administered, subject to other policy limitations.

7 Active Policies

ARKBLUE-SIROLIMUS-PROTEIN-BOUND-PARTICLES-FOR-INJECTABLE-2C36A6FF02, Sirolimus protein-bound particles for injectable suspension (e.g., Fyarro)

BCBSLA-00813-A52B398596, 00813 sirolimus topical gel (Hyftor)

POINT32HEALTH-PMNG-15836, Hyftor (sirolimus gel)

MULTI

POINT32HEALTH-PMNG-15846, Hyftor (sirolimus)

MULTI

HEALTHNET_OR-HNOR-SIROLIMUS-PROTEIN-BOUND-PARTICLES-FYARRO-TOPICAL-GEL-HYF-574237F549, Sirolimus Protein-Bound Particles (Fyarro), Topical Gel, (Hyftor); CP.PHAR.574

BCBSTN-cbcf95447c, Sirolimus protein-bound particles for injectable suspension (albumin-bound) (Fyarro)

L33824, Immunosuppressive Drugs

`J7520`, Sirolimus, oral, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

7 Active Policies

Related Codes

Have a follow-up question?

J7520, Sirolimus, oral, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

7 Active Policies

Related Codes

Have a follow-up question?

`J7520`, Sirolimus, oral, 1 mg