Does T50.995S require prior authorization?

No, T50.995S does not require prior authorization (high confidence). Covered without prior authorization.

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`T50.995S`, Adverse effect of other drugs, medicaments and biological substances, sequela

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

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.

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.

20 Active Policies

CGS-J15-L40325, Allergy Diagnostic Testing

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CGS-J15-L37598, Cystatin C Measurement

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CGS-J18-L37598, Cystatin C Measurement

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CGS-J18-L40325, Allergy Diagnostic Testing

J18

A56844, Billing and Coding: RAST Type Tests

NGS-J6-L40329, Allergy Diagnostic Testing

A52421, Billing and Coding: Ibandronate Sodium

A52450, Billing and Coding: Paclitaxel (e.g., Taxol/Abraxane )

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

NGS-J6-L33591, RAST Type Tests

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

FIRST_COAST-L33967, Vitamin B<sub>12</sub> Injections

A57531, Billing and Coding: Allergy Testing

A57678, Billing and Coding: Allergen Immunotherapy

FIRST_COAST-L33261, Allergy Testing

FIRST_COAST-L37800, Allergen Immunotherapy

NOVITAS-JH-L35049, Monitored Anesthesia Care

NOVITAS-JH-L36240, Allergen Immunotherapy

NOVITAS-JH-L36241, Allergy Testing

NGS-JK-L40329, Allergy Diagnostic Testing

`T50.995S`, Adverse effect of other drugs, medicaments and biological substances, sequela

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

T50.995S, Adverse effect of other drugs, medicaments and biological substances, sequela

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`T50.995S`, Adverse effect of other drugs, medicaments and biological substances, sequela