Does J9260 require prior authorization?

Yes, J9260 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for J9260?

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

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`J9260`, Injection, methotrexate sodium, 50 mg

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

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.

For some systemic or investigational therapy trials, baseline and end-of-study laboratory tests were obtained: "Blood samples for measurements of complete blood count along with thyroid function (T3, T4 and TSH) and liver function tests were taken at the baseline and at the end of study." (triiodothyronine trial)

Trial protocols and observational studies commonly documented: duration of current episode, baseline percent scalp hair loss, prior treatments and response, and follow-up visit schedules (e.g., "Subjects were reviewed every 3 months for 2 years", "Patients were followed-up for 3 months", "Patients received 4 to 8 sessions repeated at an interval of 3 to 4 weeks").

For intralesional corticosteroid therapy: documentation of treated patches and number/timing of monthly injections ("Multiple injections are administered monthly...an average of 4 to 6 monthly injections are usually required").

When topical immunotherapy used, documentation of treatment duration and response timing required: "Initial responses are generally seen after 12 weeks of therapy...cosmetically acceptable results in 24 weeks...If there is no response by the end of 24 weeks, immunotherapy is discontinued."

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.
Extensive alopecia areata (involving more than 50 % loss of scalp hair) — treatments may include topical immunotherapy, systemic agents or other measures: "Therapy for extensive alopecia areata (involving more than 50 % loss of scalp hair) may be prolonged and difficult...Systemic corticosteroids are seldom used due to their adverse effects; however, they may be required depending on the severity of the condition and the adequacy of the response to topical therapy."
Topical immunotherapy (DPCP/DCP and SADBE) for scalp hair loss of 50 to 99 % — "Topical immunotherapy...with reported hair growth rates of 40 to 60 % among patients with scalp hair loss of 50 to 99 %."
Psoralen photochemotherapy (PUVA) as an option for alopecia areata (used in practice by AAD despite limited evidence) — "Psoralen photochemotherapy (psoralen and ultraviolet light A or PUVA) is another immunosuppressant treatment that is used for alopecia areata...Despite these limitations, PUVA is still considered standard practice of care by the American Academy of Dermatology."
Topical 5% minoxidil for patchy alopecia areata — meta-analysis finding: "The meta-analysis involving 5% minoxidil versus placebo presented a significant difference in favor of 5% minoxidil...in children and adults with patchy AA."

5 Active Policies

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

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

AETNA-CPB-0423, Alopecia Areata

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J9260, Injection, methotrexate sodium, 50 mg