Does J8540 require prior authorization?

Yes, J8540 requires prior authorization (medium confidence). Conditional coverage; review criteria to confirm PA need.

What is the Medicare reimbursement rate for J8540?

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

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`J8540`, Dexamethasone, oral, 0.25 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; lack of a completed SWO will result in denial.
For DMEPOS base items requiring WOPD, the supplier must have a signed WOPD prior to delivery; WOPD must list the base item and may list separately billed associated options/accessories/supplies.

Suppliers are required to maintain proof of delivery (POD) documentation and make it available to the Medicare contractor upon request.

Suppliers must contact the beneficiary for DMEPOS refills and document an affirmative response prior to dispensing refills; contact must occur no sooner than 30 calendar days prior to expected end of current supply.

Treating practitioners may bill only if they are enrolled as a DMEPOS supplier with the National Supplier Clearinghouse, are dispensing the drug to the beneficiary, and are authorized by the State to dispense drugs as part of their license.

Suppliers must verify and document that any changed or atypical utilization patterns are warranted by treating practitioners before dispensing additional quantities.

Key Coverage Criteria

Coverage requires that the item meet Medicare statutory criteria (eligible benefit category and be reasonable and necessary) per Social Security Act §1862(a)(1)(A).
An FDA‑approved oral 3‑drug antiemetic regimen consisting of an oral NK‑1 antagonist plus an oral 5‑HT3 antagonist and dexamethasone (HCPCS J8540) is covered when administered to beneficiaries receiving one or more of the following chemotherapeutic agents: Alemtuzumab, Azacitidine, Bendamustine, Carboplatin, Carmustine, Cisplatin, Clofarabine, Cyclophosphamide, Cytarabine, Dacarbazine, Daunorubicin, Doxorubicin, Epirubicin, Idarubicin, Ifosfamide, Irinotecan, Lomustine, Mechlorethamine, Oxalipla [...]
Dextenza is covered for treatment of ocular inflammation following ophthalmic surgery.
Dextenza is covered for treatment of ocular pain following ophthalmic surgery.
Laser trabeculoplasty for treatment of members with refractory primary open-angle glaucoma (POAG) when first-line drugs (e.g., latanoprost or timolol) and second-line drugs (e.g., brimonidine or dorzolamide) have failed to control intra-ocular pressure (IOP).
FDA‑approved aqueous drainage/shunt implants for treatment of members with refractory primary open‑angle glaucoma when first-line and second-line drugs have failed to control IOP. (Examples listed in policy: Ahmed glaucoma implant; Baerveldt seton; Ex‑PRESS mini glaucoma shunt; Glaucoma pressure regulator; Krupin‑Denver valve implant; Molteno implant; Schocket shunt.)

9 Active Policies

ARKBLUE-DEXAMETHASONE-INTRAOCULAR-SUSPENSION-E-G-DEXYCU-DC0C87518D, Dexamethasone intraocular suspension (e.g., DEXYCU)

BCBSLA-00744-C03E45FAC4, 00744 Hemady (dexamethasone)

BCBSLA-00564-D52A0AC03A, 00564 Select Dexamethasone Packs

L33827, Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics)

AETNA-CPB-0484, Glaucoma Surgery

A58548, Response to Comments: Dexamethasone Intracanalicular Ophthalmic Insert (Dextenza)

AETNA-CPB-0422, Vitiligo

BCBSTN-97959657c5, Dexamethasone Implant (Ozurdex)

L38792, Dexamethasone Intracanalicular Ophthalmic Insert (Dextenza)

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J8540, Dexamethasone, oral, 0.25 mg