![]() ![]() ![]() HCPCS code J0897 should be used to report denosumab (Prolia™, Xgeva™) for claims submitted to the Part A and Part B MAC.When services are performed in excess of established parameters, they may be subject to review for medical necessity. Patient adequately supplemented with calcium and vitamin Dįor management of hypercalcemia of malignancy (ICD-10-CM code E83.52)ĭose and frequency should be in accordance with the FDA label or recognized compendia (for off-label uses).Additional diagnosed risk factors, if any.ĭocumentation should include, but is not limited to:įor treatment of bone metastasis from a solid tumor:.Use of adjuvant aromatase inhibitor (AI) therapy or androgen deprivation therapy (ADT).Documentation supporting the diagnosis of breast cancer or nonmetastatic prostate cancer.Risk factors for future fracture including preventive measures.įor the treatment of cancer treatment-induced bone loss (CTIBL) due to hormone ablation such documentation should include, but is not limited to:.History of previous fractures, including type of fracture, cause and time since occurrence.Previous treatment of osteoporosis, agents used, outcomes and adverse reactions if any. ![]() Documentation supporting the diagnosis of osteoporosis.Menopausal status (for female beneficiaries only).Patient adequately supplemented with calcium and vitamin D (calcium 1000 mg daily and at least 400 IU vitamin D daily).įor postmenopausal osteoporosis at high risk for fracture, documentation should include but is not limited to: Requirements specific to each formulation are as follows: The patient's medical record should contain documentation that fully supports the medical necessity for the administration of either formulation. Such determination of reasonable and necessary is currently left to the discretion of the Medicare contractors. Medicare has determined under Section 1861(t) that this drug may be paid when it is administered incident to a physician’s service and is determined to be reasonable and necessary. The FDA has approved the use of denosumab (Prolia™). Hypocalcemia must be corrected prior to initiation of denosumab therapy. Supplemental calcium and vitamin D are required. Binding to the transmembrane or soluble protein RANKL inhibits the formation, function, and survival of osteoclasts resulting in decreased bone resorption and increased bone mass and strength. This article contains billing and coding guidelines that complement the Local Coverage Determination (LCD) Drugs and Biologicals, Coverage of, for Label and Off-Label Uses.ĭenosumab is a receptor activator of nuclear factor kappa-B ligand (RANKL) inhibitor. Not endorsed by the AHA or any of its affiliates. Presented in the material do not necessarily represent the views of the AHA. Preparation of this material, or the analysis of information provided in the material. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness orĪccuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the Resale and/or to be used in any product or publication creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions Īnd/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is onlyĪuthorized with an express license from the American Hospital Association. Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816. AHA copyrighted materials including the UB‐04 codes andĭescriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may beĬopied without the express written consent of the AHA. All rights reserved.Ĭopyright © 2023, the American Hospital Association, Chicago, Illinois. The AMA assumes no liability for data contained or not contained herein.Ĭurrent Dental Terminology © 2022 American Dental Association. The AMA does not directly or indirectly practice medicine or dispense medical services. Applicable FARS/HHSARS apply.įee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not AMA CPT / ADA CDT / AHA NUBC Copyright StatementĬPT codes, descriptions and other data only are copyright 2022 American Medical Association. ![]()
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