Does J8499 require prior authorization?

Yes, J8499 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for J8499?

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

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`J8499`, Prescription drug, oral, non chemotherapeutic, nos

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

Signed and dated office visit records and operative reports are required; all services ordered or rendered to Medicare beneficiaries must be signed.
For services requiring a referring/ordering physician, the referring/ordering physician's name and NPI must be reported on the claim.

Key Coverage Criteria

Chelation therapy is covered as medically necessary for heavy metal toxicity and overload conditions (e.g., iron, copper, lead, aluminum).
Sublingual immunotherapy with Oralair, Grastek, or Ragwitek is medically necessary for pollen-induced allergic rhinitis/rhinoconjunctivitis when used per FDA labeling and the patient has a history of rhinitis/rhinoconjunctivitis symptoms related to grass or short ragweed pollen exposure.
Sublingual immunotherapy with Oralair, Grastek, or Ragwitek is medically necessary for pollen-induced allergic rhinitis/rhinoconjunctivitis when there is a history of grass or short ragweed pollen–related symptoms, per FDA labeling.
Medically necessary SLIT with Oralair, Grastek, or Ragwitek for pollen-induced allergic rhinitis/rhinoconjunctivitis when: 1) there is a history of rhinitis/rhinoconjunctivitis symptoms related to grass or short ragweed pollen exposure; and 2) the product is used per FDA labeling.
Medically necessary Odactra for house dust mite–induced allergic rhinitis/rhinoconjunctivitis when: 1) history of rhinitis/rhinoconjunctivitis symptoms related to dust mite exposure; 2) positive HDM-specific skin test or HDM-specific IgE; 3) symptoms not adequately controlled by pharmacotherapy.
Chelation therapy for heavy metal toxicity and overload conditions (e.g., Iron, Copper, Lead, Aluminum) is proven and medically necessary.

11 Active Policies

CGS-J15-L38268, Immune Thrombocytopenia (ITP) Therapy

J15

CGS-J18-L38268, Immune Thrombocytopenia (ITP) Therapy

J18

A57160, Billing and Coding: Immune Thrombocytopenia (ITP) Therapy

UHC-POL-chelation-therapy-non-overload-conditions, Chelation Therapy

BCBSIL-MED206.006, Sublingual Immunotherapy as a Technique of Allergen-Specific Therapy

BCBSMT-MED206.006, Sublingual Immunotherapy as a Technique of Allergen-Specific Therapy

BCBSNM-MED206.006, Sublingual Immunotherapy as a Technique of Allergen-Specific Therapy

BCBSOK-MED206.006, Sublingual Immunotherapy as a Technique of Allergen-Specific Therapy

UMR-POL-UMR-chelation-therapy-non-overload-conditions, Chelation Therapy

SUREST-POL-SUREST-chelation-therapy-non-overload-conditions, Chelation Therapy

EVICORE-HPLAN-CIGNA-729A536F50C8, Q3 - 2026 Cigna MedOnc Master Drug List.pdf

`J8499`, Prescription drug, oral, non chemotherapeutic, nos

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

11 Active Policies

Related Codes

Have a follow-up question?

J8499, Prescription drug, oral, non chemotherapeutic, nos

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

11 Active Policies

Related Codes

Have a follow-up question?

`J8499`, Prescription drug, oral, non chemotherapeutic, nos