Does Q5159 require prior authorization?

Yes, Q5159 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for Q5159?

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

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`Q5159`, Injection, denosumab-dssb (ospomyv/xbryk), biosimilar, 1 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 management of hypercalcemia of malignancy document ICD-10-CM code E83.52, the related malignancy, and the rationale for denosumab use.
Medical record must contain documentation that fully supports the medical necessity for administration of the specific denosumab formulation used.

For postmenopausal osteoporosis include menopausal status (female), age and sex, documentation supporting the osteoporosis diagnosis, prior osteoporosis treatments and outcomes/adverse reactions, prior fracture history (type, cause, time), and fracture risk factors/preventive measures.

For CTIBL include documentation of breast cancer or nonmetastatic prostate cancer, use of adjuvant AI or ADT, and any additional diagnosed risk factors.

For treatment of bone metastasis document the related malignancy, the clinical rationale for denosumab use, and confirmation that the patient is adequately supplemented with calcium and vitamin D.

Use the appropriate HCPCS code for the specific denosumab product on Part A and Part B claims: J0897 for Prolia®/Xgeva®; Q5136 for Jubbonti®/Wyost®; Q5157 for denosumab-bmwo (Stoboclo®, Osenvelt®); Q5158 for denosumab-bnht (Bomyntra®, Conexxence®); Q5159 for denosumab-dssb (Ospomyv™, Xbryk™).

Key Coverage Criteria

Denosumab is covered for postmenopausal osteoporosis in patients at high risk for fracture when medical record documents menopausal status, diagnosis of osteoporosis, prior osteoporosis treatments and outcomes, fracture history, and fracture risk factors.
Denosumab is covered for cancer treatment–induced bone loss (CTIBL) in patients with breast cancer receiving adjuvant aromatase inhibitors (AI) or in patients with nonmetastatic prostate cancer receiving androgen deprivation therapy (ADT) when documentation supports the cancer diagnosis and therapy.
Denosumab is covered for treatment of bone metastasis from a solid tumor when the claim lists bone metastasis (ICD-10-CM C79.51) as the primary diagnosis and the original cancer or history of cancer is included as the secondary diagnosis.
Denosumab is covered for management of hypercalcemia of malignancy when ICD-10-CM code E83.52 and the related malignancy and clinical rationale are documented.
Denosumab (Xgeva®) is covered for treatment of skeletal-related events in patients with multiple myeloma per FDA approval effective 01/04/2018 when clinical rationale is documented.
Coverage requires that the patient be adequately supplemented with calcium (1000 mg daily) and vitamin D (at least 400 IU daily) and that hypocalcemia be corrected prior to initiation of denosumab.

11 Active Policies

A52399, Billing and Coding: Denosumab (Prolia, Xgeva, Jubbonti, Wyost, Ospomyv,Xbryk,Bomyntra, Conexxence, Stoboclo, Osenvelt,Bildyos, Bilprevda)

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

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

BCBSMT-RX501.140, Denosumab and Biosimilars for Non-Oncologic Indications

BCBSNM-RX501.140, Denosumab and Biosimilars for Non-Oncologic Indications

BCBSOK-RX501.140, Denosumab and Biosimilars for Non-Oncologic Indications

UMR-POL-UMR-denosumab-prolia-xgeva, Denosumab

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

SUREST-POL-SUREST-denosumab-prolia-xgeva, Denosumab

UHC-POL-denosumab-prolia-xgeva, Denosumab

BCBSIL-RX501.140, Denosumab and Biosimilars for Non-Oncologic Indications

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Q5159, Injection, denosumab-dssb (ospomyv/xbryk), biosimilar, 1 mg