Does J9267 require prior authorization?

Yes, J9267 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for J9267?

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

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`J9267`, Injection, paclitaxel, 1 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

When reporting the JW modifier for discarded drug, the medical record must clearly show the amount administered and the amount wasted.
Medical record must document prior anthracycline therapy for patients receiving albumin-bound paclitaxel, or clearly document a clinical contraindication to anthracycline therapy.

For claims with no discarded amounts from single-dose containers or single-use packages, include the JZ modifier as evidence on the claim (effective July 1, 2023).

Document dose and frequency as consistent with the FDA label or recognized compendia for the indication (including citations to the compendia if used for off-label indications).

Maintain documentation supporting coding decisions for metastatic disease (e.g., evidence primary malignancy still present vs. use of 'personal history of' Z-code).

Coverage determinations for off-label use require supporting peer-reviewed literature, specialty consultant advice as indicated, and reference to accepted standards of medical practice; documentation of these sources must be provided for review.

Key Coverage Criteria

Paclitaxel administered intravenously is covered for antineoplastic (cancer) indications when used in accordance with the FDA-approved labeling.
Off-label uses of paclitaxel are covered when supported by recognized compendia (e.g., NCCN, AHFS, Clinical Pharmacology, Lexi-Drugs, Micromedex) and dosing/frequency follow those compendia.
Albumin-bound paclitaxel (Abraxane) is covered when prior therapy included an anthracycline unless anthracycline therapy is clinically contraindicated.
Covered indications include FDA-approved indications and compendial uses, provided that all approval criteria are met and the member has no exclusions to the prescribed therapy.
NGS covers leuprolide acetate (LHRH analog) as palliative treatment of advanced breast carcinoma in premenopausal and perimenopausal women.
A drug use is covered if it is an FDA-approved labeled indication or is a medically accepted off-label indication supported by one of the accepted compendia at the specified levels (AHFS-DI supportive; NCCN Category 1 or 2A; Micromedex DrugDex Class I/IIa/IIb or Clinical Pharmacology supportive; Lexi-Drugs Evidence Level A) or by articles or LCDs published by National Government Services (NGS).

10 Active Policies

ARKBLUE-NAB-PACLITAXEL-E-G-ABRAXANE-359D00459A, Nab-Paclitaxel (e.g., Abraxane)

A52450, Billing and Coding: Paclitaxel (e.g., Taxol/Abraxane )

NGS-J6-L33394, Drugs and Biologicals, Coverage of, for Label and Off-Label Uses

NGS-JK-L33394, Drugs and Biologicals, Coverage of, for Label and Off-Label Uses

BCBSM-2070042-1AD4063D40, NAB-PACLITAXEL; PACLITAXEL PROTEIN-BOUND PARTICLES

POINT32HEALTH-MDMNG-24056, Abraxane (paclitaxel protein bound)

MULTI

MODA-CUSTOM-MODA-MRXM-PACLITAXEL-ALBUMIN-BOUND-E-CCE79C8DD6, Paclitaxel Albumin-Bound: Abraxane; Paclitaxel Albumin-Bound

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

BCBSTN-2a7cc49102, Paclitaxel (Albumin-Bound) (Abraxane; Paclitaxel Albumin-Bound)

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

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J9267, Injection, paclitaxel, 1 mg