Does Q5121 require prior authorization?

Yes, Q5121 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for Q5121?

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

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`Q5121`, Injection, infliximab-axxq, biosimilar, (avsola), 10 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

Medical records must document the basis for each diagnosis and that diagnoses follow recognized standards (eg, American College of Rheumatology guidelines).
Medical records must include patient weight when needed to determine appropriate dosing.
Medical records must document evaluation for latent tuberculosis infection with a medical evaluation and TB test, and initiation of latent TB treatment prior to infliximab when indicated.
Medical records must document disease‑specific relevant symptoms and signs that are being treated and monitored to assess response to treatment.
For biologic initiation, documentation must show inadequate response (lack of efficacy, adverse effects, or contraindication) to a 3‑month trial of appropriately dosed, disease‑specific conventional (non‑biologic) therapy.
For plaque psoriasis, documentation should include percent body surface area affected, PASI score, PDI score, or other psoriasis assessment tools and documentation of planned close follow‑up; monitor for nonmelanoma skin cancer especially after prior prolonged phototherapy.

Key Coverage Criteria

Infliximab and its FDA‑approved biosimilars are covered when administered in accordance with the FDA‑approved label or recognized compendia for labeled and off‑label uses.
Covered for Crohn's disease when medical records document disease‑specific signs/symptoms (eg, abdominal pain, diarrhea, fistulae) and dosing per label or compendia; retreatment is covered if prior initial treatment produced reduction in clinical signs and symptoms.
Covered for rheumatoid arthritis when prescribed per label/compendia and medical record documents concomitant methotrexate use or a documented contraindication to methotrexate.
Covered for plaque psoriasis when documentation shows chronic, severe, extensive, or disabling disease (eg, percent BSA, PASI, or PDI) and the patient will have close physician follow‑up and monitoring.
Claims for pyoderma gangrenosum with coexisting inflammatory bowel disease are covered when the claim includes both primary and secondary ICD‑10‑CM diagnosis codes documenting pyoderma gangrenosum and IBD.
ICD-10 codes covered if selection criteria are met: H44.131 - H44.139 Sympathetic uveitis

20 Active Policies

A52423, Billing and Coding: Infliximab and biosimilars

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

PALMETTO-JJ-L35677, Infliximab

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

PALMETTO-JM-L35677, Infliximab

BCBSLA-00712-70F56030FD, 00712 infliximab-axxq (Avsola)- Retired Policy

BCBSNJ-DRUGS-017-43C6A62377, Infliximab (Remicade), infliximab-dyyb (Inflectra), and infliximab-abda (Renflexis), infliximab-qbtx (Ixifi), and infliximab-axxq (Avsola)

MODA-INFLIXIMABS-D4B3E4C40B, Infliximab: Remicade; Inflectra; Renflexis; Avsola; Infliximab*

BCBSIL-RX501.051, Infliximab and Associated Biosimilars

BCBSIL-ADM1001.034, Specialty Medication Administration Site of Care

BCBSMT-RX501.051, Infliximab and Associated Biosimilars

BCBSMT-ADM1001.034, Specialty Medication Administration Site of Care

BCBSNM-RX501.051, Infliximab and Associated Biosimilars

BCBSNM-ADM1001.034, Specialty Medication Administration Site of Care

BCBSOK-RX501.051, Infliximab and Associated Biosimilars

BCBSOK-ADM1001.034, Specialty Medication Administration Site of Care

UMR-POL-UMR-infliximab-remicade-inflectra, Infliximab (Avsola, Inflectra, Remicade, & Renflexis)

UMR-POL-UMR-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care

SUREST-POL-SUREST-infliximab-remicade-inflectra, Infliximab (Avsola, Inflectra, Remicade, & Renflexis)

AETNA-CPB-0341, Infliximab

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Q5121, Injection, infliximab-axxq, biosimilar, (avsola), 10 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

Medical records must document the basis for each diagnosis and that diagnoses follow recognized standards (eg, American College of Rheumatology guidelines).
Medical records must include patient weight when needed to determine appropriate dosing.
Medical records must document evaluation for latent tuberculosis infection with a medical evaluation and TB test, and initiation of latent TB treatment prior to infliximab when indicated.
Medical records must document disease‑specific relevant symptoms and signs that are being treated and monitored to assess response to treatment.
For biologic initiation, documentation must show inadequate response (lack of efficacy, adverse effects, or contraindication) to a 3‑month trial of appropriately dosed, disease‑specific conventional (non‑biologic) therapy.
For plaque psoriasis, documentation should include percent body surface area affected, PASI score, PDI score, or other psoriasis assessment tools and documentation of planned close follow‑up; monitor for nonmelanoma skin cancer especially after prior prolonged phototherapy.

Key Coverage Criteria

Infliximab and its FDA‑approved biosimilars are covered when administered in accordance with the FDA‑approved label or recognized compendia for labeled and off‑label uses.
Covered for Crohn's disease when medical records document disease‑specific signs/symptoms (eg, abdominal pain, diarrhea, fistulae) and dosing per label or compendia; retreatment is covered if prior initial treatment produced reduction in clinical signs and symptoms.
Covered for rheumatoid arthritis when prescribed per label/compendia and medical record documents concomitant methotrexate use or a documented contraindication to methotrexate.
Covered for plaque psoriasis when documentation shows chronic, severe, extensive, or disabling disease (eg, percent BSA, PASI, or PDI) and the patient will have close physician follow‑up and monitoring.
Claims for pyoderma gangrenosum with coexisting inflammatory bowel disease are covered when the claim includes both primary and secondary ICD‑10‑CM diagnosis codes documenting pyoderma gangrenosum and IBD.
ICD-10 codes covered if selection criteria are met: H44.131 - H44.139 Sympathetic uveitis

20 Active Policies

A52423, Billing and Coding: Infliximab and biosimilars

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

PALMETTO-JJ-L35677, Infliximab

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

PALMETTO-JM-L35677, Infliximab

BCBSLA-00712-70F56030FD, 00712 infliximab-axxq (Avsola)- Retired Policy

BCBSNJ-DRUGS-017-43C6A62377, Infliximab (Remicade), infliximab-dyyb (Inflectra), and infliximab-abda (Renflexis), infliximab-qbtx (Ixifi), and infliximab-axxq (Avsola)

MODA-INFLIXIMABS-D4B3E4C40B, Infliximab: Remicade; Inflectra; Renflexis; Avsola; Infliximab*

BCBSIL-RX501.051, Infliximab and Associated Biosimilars

BCBSIL-ADM1001.034, Specialty Medication Administration Site of Care

BCBSMT-RX501.051, Infliximab and Associated Biosimilars

BCBSMT-ADM1001.034, Specialty Medication Administration Site of Care

BCBSNM-RX501.051, Infliximab and Associated Biosimilars

BCBSNM-ADM1001.034, Specialty Medication Administration Site of Care

BCBSOK-RX501.051, Infliximab and Associated Biosimilars

BCBSOK-ADM1001.034, Specialty Medication Administration Site of Care

UMR-POL-UMR-infliximab-remicade-inflectra, Infliximab (Avsola, Inflectra, Remicade, & Renflexis)

UMR-POL-UMR-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care

SUREST-POL-SUREST-infliximab-remicade-inflectra, Infliximab (Avsola, Inflectra, Remicade, & Renflexis)

AETNA-CPB-0341, Infliximab

Have a follow-up question?

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

Ask Backwork about Q5121 Sign up free

`Q5121`, Injection, infliximab-axxq, biosimilar, (avsola), 10 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`Q5121`, Injection, infliximab-axxq, biosimilar, (avsola), 10 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

Q5121, Injection, infliximab-axxq, biosimilar, (avsola), 10 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

Q5121, Injection, infliximab-axxq, biosimilar, (avsola), 10 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`Q5121`, Injection, infliximab-axxq, biosimilar, (avsola), 10 mg

`Q5121`, Injection, infliximab-axxq, biosimilar, (avsola), 10 mg