Does J9190 require prior authorization?

Yes, J9190 requires prior authorization (high confidence). Code explicitly requires prior authorization.

What is the Medicare reimbursement rate for J9190?

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

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`J9190`, Injection, fluorouracil, 500 mg

HCPCS/CPT

Prior Authorization

Prior Auth Required

Code explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

Claims must be supported by medical record documentation of the patient’s diagnosis/clinical condition and justification that the selected drug, dose, and route of administration are appropriate and medically necessary for the non-oncologic indication.

Billing must comply with Medicare rules and any applicable LCD prior authorization or documentation requirements; follow any specific forms or prior authorization processes required by the LCD or payer.

A Standard Written Order (SWO) must be communicated to the supplier before claim submission and a signed Written Order Prior to Delivery (WOPD) must be received before delivery of DMEPOS base items that require WOPD.

Proof of delivery (POD) documentation must be maintained by the supplier and be made available to the Medicare contractor upon request; claims without appropriate POD will be denied.

For insulin pump coverage, document C-peptide testing (meeting specified thresholds), beta cell autoantibody positivity, comprehensive diabetes education completion, prior multiple daily injection regimen (≥3 injections/day for ≥6 months) with self-adjustments, and documented glucose self-testing frequency (average ≥4 times/day for 2 months prior to initiation or ≥4 times/day during the month prior to Medicare enrollment if previously on a pump).

For inotropic therapy coverage, document failure of guideline-directed medical therapy (GDMT), cardiologist evaluation with training in advanced HF, documented symptomatic improvement on the selected inotropic drug at discharge, and planned three-month re-evaluations by the prescribing provider or heart failure team.

Key Coverage Criteria

Anti-neoplastic (chemotherapy) agent CPT/HCPCS codes may be used to bill for administration of these drugs when given to treat non-oncologic (noncancer) diagnoses if the drug is medically necessary for the patient’s condition and consistent with the standard of medical practice.
Monoclonal antibody agents and other biologic response modifiers may be administered and billed using chemotherapy administration codes for noncancer indications when the dose, route, and clinical use are appropriate and medically necessary.
External infusion pumps (HCPCS E0779, E0780, E0781, E0791) are covered for administration of deferoxamine for treatment of chronic iron overload.
External infusion pumps are covered for administration of anticancer chemotherapy for unresectable primary hepatocellular carcinoma or unresectable colorectal cancer or when the beneficiary refuses surgical excision of the tumor.
External infusion pumps are covered for administration of morphine for intractable cancer pain.
Continuous subcutaneous insulin infusion (pump E0784) is covered for diabetes mellitus when the beneficiary meets either criterion A (C-peptide/autoantibody evidence of insulin deficiency) or B (prior successful insulin pump use before Medicare enrollment) and either criterion C (prior multiple daily injection program with documented deficiencies) or D (prior pump use with documented glucose testing).

18 Active Policies

ARKBLUE-GENETIC-TEST-LABORATORY-AND-GENETIC-TESTING-FOR-017AF3C957, Genetic Test: Laboratory and Genetic Testing for Use of 5-Fluorouracil in Patients with Cancer

FLORIDA_BLUE-FLBLUE-THERAPEUTIC-DRUG-MONITORING-FOR-5-FLUOROURACIL-FFC4F7C62E, Therapeutic Drug Monitoring for 5-Fluorouracil

WPS-J5-L37205, Chemotherapy Drugs and their Adjuncts

A55639, Billing and Coding: Chemotherapy Agents for Non-Oncologic Conditions

WPS-J8-L37205, Chemotherapy Drugs and their Adjuncts

BCBSLA-00291-89C0AD378D, 00291 Laboratory and Genetic Testing for Use of 5-Fluorouracil in Patients With Cancer- Retired Policy

BCBSM-2019297-2334662EC7, GENETIC AND LABORATORY TESTING FOR USE OF FLUOROPYRIMIDINES (E.G., 5-FLUOROURACIL AND CAPECITABINE) IN PATIENTS WITH CANCER

BCBSMS-A-2-04-68-87BEB00EAC, Laboratory and Genetic Testing for Use of 5-Fluorouracil in Patients With Cancer

BCBSNC-TESTING-FOR-5-FLUOROURACIL-USE-IN-CANCER-PATIENTS-AHS-M2067-4148158AD5, Testing for 5-Fluorouracil Use in Cancer Patients AHS - M2067

BCBSNJ-PATHOLOGY-070-4D5E945F7B, Laboratory and Genetic Testing for Use of 5-Fluorouracil in Patients With Cancer

HEALTHNET_OR-HNOR-FLUOROURACIL-CREAM-TOLAK-CP-PMN-165-637B5ED00D, Fluorouracil Cream (Tolak); CP.PMN.165

CIGNA-0328, Scar Revision

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

PREMERA-15-01-044-THERAPEUTIC-DRUG-MONITORING-FOR-5-FLUOROURACIL-93E553278F, 15.01.044 Therapeutic Drug Monitoring for 5-Fluorouracil

L33794, External Infusion Pumps

AETNA-CPB-0484, Glaucoma Surgery

AETNA-CPB-0389, Hypertrophic Scars and Keloids

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

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J9190, Injection, fluorouracil, 500 mg