Does Q5123 require prior authorization?

Yes, Q5123 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for Q5123?

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

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`Q5123`, Injection, rituximab-arrx, biosimilar, (riabni), 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

Claims must be supported by medical record documentation of the patient’s diagnosis/clinical condition and justification that the selected drug, dose, and route of administration are appropriate and medically necessary for the non-oncologic indication.
Billing must comply with Medicare rules and any applicable LCD prior authorization or documentation requirements; follow any specific forms or prior authorization processes required by the LCD or payer.
The medical record must include the assessment by the ordering provider as it relates to the patient's complaint for that visit.
Document relevant medical history, results of pertinent tests/procedures, and signed and dated office visit records or operative reports.
Document previous treatments including medication(s), dosing, frequency, duration of treatment(s), and documentation of response(s).
If use is due to lack of efficacy, include documentation of prior treatment(s) with dosing, frequency, duration, and response(s).

Key Coverage Criteria

Anti-neoplastic (chemotherapy) agent CPT/HCPCS codes may be used to bill for administration of these drugs when given to treat non-oncologic (noncancer) diagnoses if the drug is medically necessary for the patient’s condition and consistent with the standard of medical practice.
Monoclonal antibody agents and other biologic response modifiers may be administered and billed using chemotherapy administration codes for noncancer indications when the dose, route, and clinical use are appropriate and medically necessary.
Off-label use of rituximab or rituximab biosimilars is allowable when the patient has documented lack of efficacy of prior treatments, including dosing, frequency, duration, and documentation of response(s).
Off-label use is allowable when first-line therapy produced an adverse reaction that absolutely contraindicates further use or causes non-transient side effects that impair functional capacity or activities of daily living, with the adverse event documented.
Off-label use is allowable for refractory disease when documentation includes all first-line treatment(s) with dosing, frequency, duration, and documentation of response(s).
Off-label use is allowable for disease relapse when documentation includes prior first-line treatment(s) with dosing, frequency, duration, duration of improvement on prior treatment(s), pertinent clinical history, exam findings, test results supporting relapse, and documentation of response to treatment at time of relapse.

20 Active Policies

WPS-J5-L37205, Chemotherapy Drugs and their Adjuncts

A55639, Billing and Coding: Chemotherapy Agents for Non-Oncologic Conditions

NGS-J6-L39297, Off-label Use of Rituximab and Rituximab Biosimilars

A59101, Billing and Coding: Off-label Use of Rituximab and Rituximab Biosimilars

WPS-J8-L37205, Chemotherapy Drugs and their Adjuncts

PALMETTO-JJ-L35026, Rituximab

NGS-JK-L39297, Off-label Use of Rituximab and Rituximab Biosimilars

PALMETTO-JM-L35026, Rituximab

HEALTHPARTNERS-CC-ENTRY-228488, Oncology** - rituximab (Rituxan, Ruxience, Truxima, Rituxan Hycela, and Riabni) – Minnesota Health Care Programs

MULTI

HEALTHPARTNERS-CC-AENTRY-046128, Oncology** - rituximab (Rituxan, Ruxience, Truxima, Rituxan Hycela, and Riabni)

MULTI

BCBSNE-X-178-1ED0333887, RITUXAN (RITUXIMAB) & RIABNI (RITUZIMAB) PREAUTHORIZATION REQUIRED

MODA-RITUXIMAB-IV-6C6F4B5395, Rituximab: Rituxan, Truxima, Ruxience, Riabni

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

BCBSMT-RX502.061, Oncology Medications

BCBSMT-RX502.030, Rituximab and Biosimilars for Non-Oncologic Indications

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

BCBSNM-RX502.061, Oncology Medications

BCBSNM-RX502.030, Rituximab and Biosimilars for Non-Oncologic Indications

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

BCBSOK-RX502.061, Oncology Medications

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Q5123, Injection, rituximab-arrx, biosimilar, (riabni), 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

Claims must be supported by medical record documentation of the patient’s diagnosis/clinical condition and justification that the selected drug, dose, and route of administration are appropriate and medically necessary for the non-oncologic indication.
Billing must comply with Medicare rules and any applicable LCD prior authorization or documentation requirements; follow any specific forms or prior authorization processes required by the LCD or payer.
The medical record must include the assessment by the ordering provider as it relates to the patient's complaint for that visit.
Document relevant medical history, results of pertinent tests/procedures, and signed and dated office visit records or operative reports.
Document previous treatments including medication(s), dosing, frequency, duration of treatment(s), and documentation of response(s).
If use is due to lack of efficacy, include documentation of prior treatment(s) with dosing, frequency, duration, and response(s).

Key Coverage Criteria

Anti-neoplastic (chemotherapy) agent CPT/HCPCS codes may be used to bill for administration of these drugs when given to treat non-oncologic (noncancer) diagnoses if the drug is medically necessary for the patient’s condition and consistent with the standard of medical practice.
Monoclonal antibody agents and other biologic response modifiers may be administered and billed using chemotherapy administration codes for noncancer indications when the dose, route, and clinical use are appropriate and medically necessary.
Off-label use of rituximab or rituximab biosimilars is allowable when the patient has documented lack of efficacy of prior treatments, including dosing, frequency, duration, and documentation of response(s).
Off-label use is allowable when first-line therapy produced an adverse reaction that absolutely contraindicates further use or causes non-transient side effects that impair functional capacity or activities of daily living, with the adverse event documented.
Off-label use is allowable for refractory disease when documentation includes all first-line treatment(s) with dosing, frequency, duration, and documentation of response(s).
Off-label use is allowable for disease relapse when documentation includes prior first-line treatment(s) with dosing, frequency, duration, duration of improvement on prior treatment(s), pertinent clinical history, exam findings, test results supporting relapse, and documentation of response to treatment at time of relapse.

20 Active Policies

WPS-J5-L37205, Chemotherapy Drugs and their Adjuncts

A55639, Billing and Coding: Chemotherapy Agents for Non-Oncologic Conditions

NGS-J6-L39297, Off-label Use of Rituximab and Rituximab Biosimilars

A59101, Billing and Coding: Off-label Use of Rituximab and Rituximab Biosimilars

WPS-J8-L37205, Chemotherapy Drugs and their Adjuncts

PALMETTO-JJ-L35026, Rituximab

NGS-JK-L39297, Off-label Use of Rituximab and Rituximab Biosimilars

PALMETTO-JM-L35026, Rituximab

HEALTHPARTNERS-CC-ENTRY-228488, Oncology** - rituximab (Rituxan, Ruxience, Truxima, Rituxan Hycela, and Riabni) – Minnesota Health Care Programs

MULTI

HEALTHPARTNERS-CC-AENTRY-046128, Oncology** - rituximab (Rituxan, Ruxience, Truxima, Rituxan Hycela, and Riabni)

MULTI

BCBSNE-X-178-1ED0333887, RITUXAN (RITUXIMAB) & RIABNI (RITUZIMAB) PREAUTHORIZATION REQUIRED

MODA-RITUXIMAB-IV-6C6F4B5395, Rituximab: Rituxan, Truxima, Ruxience, Riabni

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

BCBSMT-RX502.061, Oncology Medications

BCBSMT-RX502.030, Rituximab and Biosimilars for Non-Oncologic Indications

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

BCBSNM-RX502.061, Oncology Medications

BCBSNM-RX502.030, Rituximab and Biosimilars for Non-Oncologic Indications

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

BCBSOK-RX502.061, Oncology Medications

Have a follow-up question?

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

Ask Backwork about Q5123 Sign up free

`Q5123`, Injection, rituximab-arrx, biosimilar, (riabni), 10 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`Q5123`, Injection, rituximab-arrx, biosimilar, (riabni), 10 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

Q5123, Injection, rituximab-arrx, biosimilar, (riabni), 10 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

Q5123, Injection, rituximab-arrx, biosimilar, (riabni), 10 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`Q5123`, Injection, rituximab-arrx, biosimilar, (riabni), 10 mg

`Q5123`, Injection, rituximab-arrx, biosimilar, (riabni), 10 mg