Does J9280 require prior authorization?

Yes, J9280 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for J9280?

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

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`J9280`, Injection, mitomycin, 5 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

Pre-operative documentation of diagnosis (e.g., OAG/POAG, OHT, refractory glaucoma) and indication for surgery (e.g., inadequate IOP control on medical therapy, need for surgical intervention).
Pre- and post-operative intraocular pressure (IOP) measurements, including medicated IOP and, where performed, unmedicated/post-washout IOP or mean diurnal IOP (many studies used medicated and post-washout IOPs and mean diurnal IOP as endpoints).

Key Coverage Criteria

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.)
Ab interno Kahook Dual Blade trabeculectomy — described as used for primary congenital glaucoma in case reports (Harvey and Schmitz 2020) and discussed as a minimally invasive technique.
Ab interno supraciliary microstent surgery (e.g., CyPass) — RCT evidence showed superiority combined with phacoemulsification vs phaco alone at 24 months, but long-term safety concerns (endothelial cell loss) led to device withdrawal (Cochrane review summary).
Non-penetrating deep sclerectomy (NPDS) with intra-scleral implant and adjunctive mitomycin C — used in eyes with uncontrolled glaucoma after DSAEK in small case series (Munoz-Negrete et al. 2015).
Trabeculectomy with adjunctive beta irradiation or antimetabolites — beta irradiation at time of trabeculectomy shown in trials to lower surgical failure but increase cataract risk (Cochrane review).

13 Active Policies

ARKBLUE-MITOMYCIN-GEL-E-G-JELMYTO-C7E55ECF67, Mitomycin Gel (e.g., Jelmyto)

ARKBLUE-MITOMYCIN-INTRAVESICAL-SOLUTION-E-G-ZUSDURI-975E9BEAF3, Mitomycin Intravesical Solution (e.g., Zusduri)

FLORIDA_BLUE-FLBLUE-MITOMYCIN-FOR-PYELOCALYCEAL-SOLUTION-JELMYTO-952C4B8B9F, Mitomycin for Pyelocalyceal Solution (Jelmyto)

BCBSNJ-DRUGS-206-E9A4AEB6C4, Mitomycin for Pyelocalyceal Solution (Jelmyto)

MODA-ZUSDURI-D137427D83, Zusduri (mitomycin)

HEALTHNET_OR-HNOR-MITOMYCIN-INSTILLATION-SOLUTION-JELMYTO-ZUSDURI-CP-PHAR-673101ECD5, Mitomycin Instillation Solution (Jelmyto, Zusduri); CP.PHAR.495

MODA-JELMYTO-D8C5FFAF4E, Jelmyto (mitomycin)

AETNA-CPB-0389, Hypertrophic Scars and Keloids

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

BCBSTN-0b2495143c, Mitomycin (Zusduri)

BCBSTN-bcb0da477a, Mitomycin Gel(Jelmyto)

AETNA-CPB-0484, Glaucoma Surgery

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

`J9280`, Injection, mitomycin, 5 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

13 Active Policies

Related Codes

Have a follow-up question?

J9280, Injection, mitomycin, 5 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

13 Active Policies

Related Codes

Have a follow-up question?

`J9280`, Injection, mitomycin, 5 mg