Does J9600 require prior authorization?

Yes, J9600 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for J9600?

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

Backwork Sign up free

`J9600`, Injection, porfimer sodium, 75 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

For Barrett's esophagus carcinoma in-situ: documentation that member is not a candidate for esophagectomy (policy language: "Barrett's esophagus carcinoma in-situ and high-grade disease in members who are not candidates for esophagectomy").

For microinvasive endobronchial non-small cell lung cancer: documentation that surgery and radiotherapy are not indicated (policy language: "Microinvasive endobronchial non-small cell lung cancer at an early stage, for whom surgery and radiotherapy are not indicated").

For cholangiocarcinoma: documentation that disease is inoperable and that PDT is being used "as an adjunct to stenting for palliation of inoperable cholangiocarcinoma."

For skin lesion indications: documentation that surgery or radiation is contraindicated or impractical when required by the policy (e.g., "methyl aminolevulinate for low-risk, squamous cell carcinoma in-situ where surgery or radiation is contraindicated or impractical").

Documented diagnosis supporting the covered indication (e.g., pathology/histology for carcinoma in-situ, ICD-10 diagnosis corresponding to the policy's covered diagnosis list).

Key Coverage Criteria

Aetna considers photodynamic therapy medically necessary as an adjunct to stenting for palliation of inoperable cholangiocarcinoma.
Aetna considers photodynamic therapy with light-activated porfimer sodium (Photofrin) medically necessary for esophageal cancer in members with any of the following: Barrett's esophagus carcinoma in-situ and high-grade disease in members who are not candidates for esophagectomy; or Completely obstructing esophageal cancer; or Partially obstructing esophageal cancer, in members who can not be satisfactorily treated with Nd:YAG laser therapy.
Aetna considers photodynamic therapy with light-activated porfimer sodium medically necessary for members with any of the following: Completely obstructing endobronchial non-small cell lung cancer; or Microinvasive endobronchial non-small cell lung cancer at an early stage, for whom surgery and radiotherapy are not indicated; or Partially obstructing endobronchial non-small cell lung cancer.
Aetna considers the following medically necessary: Photodynamic therapy using topical photosensitizers (e.g., topical methyl aminolevulinate (Metvix PDT), topical 5-fluorouracil, aminolevulinic acid (Levulan Kerastik)) for members with any of the following non-melanoma skin tumors (including pre-malignant and primary non-metastatic skin lesions): Basal cell carcinoma; or Cutaneous lesions of Bowen's disease; or Refractory actinic keratoses (see CPB 0567 - Actinic Keratoses Treatments);
Photodynamic therapy using methyl aminolevulinate for low-risk, squamous cell carcinoma in-situ where surgery or radiation is contraindicated or impractical.
Photodynamic therapy using aminolevulinic acid or methyl aminolevulinate for erythroplasia of Queyrat.

2 Active Policies

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

AETNA-CPB-0375, Photodynamic Therapy

Have a follow-up question?

Ask Backwork about documentation requirements, denial risks, or coverage in your state.

Ask Backwork about J9600 Sign up free

J9600, Injection, porfimer sodium, 75 mg