Does Q2043 require prior authorization?

Yes, Q2043 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for Q2043?

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

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`Q2043`, Sipuleucel-t, minimum of 50 million autologous cd54+ cells activated with

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

Medical records must document that sipuleucel-T is being used according to NCD 110.22 and consistent with the FDA label, including documentation of diagnosis, symptom status (asymptomatic or minimally symptomatic), and that the autologous cellular process (leukapheresis, activation, reinfusion) was followed.

Key Coverage Criteria

Sipuleucel-T is covered for patients with asymptomatic or minimally symptomatic metastatic castrate-resistant (hormone-refractory) prostate cancer when used according to NCD 110.22 and consistent with the FDA label.
Coverage applies only for the FDA-approved autologous cellular immunotherapy procedure involving leukapheresis, antigen activation, and reinfusion administered as described in the product labeling.
Medically necessary when the drug is FDA‑approved and administered in accordance with FDA labeling for an oncologic indication.
Medically necessary when the drug has an NCCN category 1, 2A, or 2B recommendation or is listed in the NCCN Drugs & Biologics Compendium.
Medically necessary when the drug is FDA‑approved and administered in accordance with FDA labeling for an oncologic indication.
Medically necessary when the drug has an NCCN category 1, 2A, or 2B recommendation or is listed in the NCCN Drugs & Biologics Compendium.

20 Active Policies

ARKBLUE-SIPULEUCEL-T-E-G-PROVENGE-FOR-THE-TREATMENT-OF-P-6E61EFD59C, Sipuleucel-T (e.g., Provenge) for the Treatment of Prostate Cancer

BCBSLA-00264-35A9890F5B, 00264 sipuleucel-T (Provenge)

MGBHP-PROVENGE-0D03BF0646, Provenge

BCBSM-2070041-8A04870D21, AIM MEDICAL POLICY - SIPULEUCEL-T: PROVENGE (Q2043) (RETIRED AS OF 02/02/2023)

POINT32HEALTH-MDMNG-13496, Provenge (sipuleucel-T)

MULTI

BCBSNJ-DRUGS-078-A871F7810B, Sipuleucel-T (Provenge)

HEALTHNET_OR-HNOR-SIPULEUCEL-T-PROVENGE-CP-PHAR-120-E94FE8E71D, Sipuleucel-T (Provenge); CP.PHAR.120

MODA-SIPULEUCEL-4D7E043ECC, Provenge (sipuleucel-T)

IBX-MEDICARE-ADVANTAGE-MA08-053B-4B830FB073, Personalized Vaccines (e.g., Provenge)

IBX-COMMERCIAL-08-00-95F-4CF90606CF, Personalized Vaccines (e.g., Provenge)

BCBSOK-RX502.061, Oncology Medications

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

AMERIHEALTH-COMMERCIAL-08-00-95F-627D9F19BC, Personalized Vaccines (e.g., Provenge)

AMERIHEALTH-MEDICARE-ADVANTAGE-MA08-053B-F2089C33A7, Personalized Vaccines (e.g., Provenge)

BCBSTN-b1549241fe, Sipuleucel-T (Provenge)

A55719, Sipuleucel-T (Provenge) - Coverage Criteria for Prostate Cancer Clarification

BCBSIL-RX502.061, Oncology Medications

BCBSMT-RX502.061, Oncology Medications

BCBSNM-RX502.061, Oncology Medications

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

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Q2043, Sipuleucel-t, minimum of 50 million autologous cd54+ cells activated with