Does Q5162 require prior authorization?

Yes, Q5162 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for Q5162?

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

Backwork Sign up free

`Q5162`, Injection, denosumab-nxxp (bildyos/bilprevda), 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

Procedure codes listed are for general reference and may not be all-inclusive.
Benefit coverage/reimbursement determinations must be based on the written coverage position in the Medical Policy, not on the presence or absence of listed codes.

Key Coverage Criteria

Initiation of denosumab (for glucocorticoid-induced osteoporosis) requires: diagnosis of glucocorticoid-induced osteoporosis; high fracture risk; dosing per FDA labeling; authorization for up to 12 months. Reauthorization requires positive clinical response, FDA-label dosing, and up to 12 months.
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.
Denosumab (Prolia®) and its biosimilars are medically necessary for postmenopausal osteoporosis with history of fragility fractures OR T-score ≤ -2.5 and high fracture risk; or osteoporosis in men with history of fragility fractures OR T-score ≤ -2.5 and high risk; or glucocorticoid-induced osteoporosis with T-score ≤ -2.5 or fragility fracture AND ongoing prednisone ≥5 mg/day for ≥6 months.
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.

19 Active Policies

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

BCBSTN-0752d743da, Denosumab Products: (Prolia); Denosumab-nxxp (Bildyos); Denosumab-mobz (Boncresa);Denosumab-kyqq (Bosaya); Denosumab-bnht (Conexxence); Denosumab-qbde (Enoby); Denosumab-bbdz (Jubbonti); Denosumab-dssb (Ospomyv); Denosumab-desu (Osvyrti); Denosumab-bmwo (Stoboclo

BCBSTN-09907bc27a, Denosumab Products: (Xgeva); Denosumab-kyqq (Aukelso); Denosumab-nxxp (Bilprevda); Denosumab-bnht (Bomyntra); Denosumab-desu (Jubereq); Denosumab-bmwo (Osenvelt); Denosumab-mobz (Oziltus); Denosumab-bbdz (Wyost); Denosumab-dssb (Xbryk), Denosumab-qbde (Xtrenbo)

EVICORE-MEDICAL_DRUG-419F2FD5372F, Denosumab Products (Prolia, Jubbonti, Stoboclo, Conexxence, Bildyos, Ospomyv, Bosaya, Enoby, Osvyrti) Non-oncologyEffective 10/01/2026

EVICORE-MEDICAL_DRUG-8A7C48EA6F23, Denosumab Products (Prolia, Jubbonti, Stoboclo, Conexxence, Bildyos, Ospomyv, Bosaya, Enoby) Non-oncology

UHC-POL-denosumab-prolia-xgeva, Denosumab

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

BCBSIL-RX502.061, Oncology Medications

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

BCBSMT-RX502.061, Oncology Medications

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

BCBSNM-RX502.061, Oncology Medications

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

BCBSOK-RX502.061, Oncology Medications

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

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

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

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

`Q5162`, Injection, denosumab-nxxp (bildyos/bilprevda), biosimilar, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

19 Active Policies

Related Codes

Have a follow-up question?

Q5162, Injection, denosumab-nxxp (bildyos/bilprevda), biosimilar, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

19 Active Policies

Related Codes

Have a follow-up question?

`Q5162`, Injection, denosumab-nxxp (bildyos/bilprevda), biosimilar, 1 mg