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Coverage and Limitations for Boniva, Zometa, Reclast, Prolia and Xgeva


Bisphosphonates

Reclast®

HCPCS code J3488, injection, zoledronic acid, (Reclast) 1 mg should not be billed on the same claim as J3487 (Zometa). Reclast® is indicated for the following indications:

Paget’s disease (also *re-treatment of Paget’s disease)

Postmenopausal osteoporosis

Osteoporosis in men

Treatment and prevention of glucocorticoid –induced osteoporosis in patients

HCPCS code J3488 (Injection, zoledronic acid [Reclast] 1 mg) should be used to report Reclast®.

The number of units billed on a claim should be 5, since Relcast® is given as a single 5 mg injection.

Reclast is only administered once per 12 months, therefore, only one Reclast® claim should be submitted per year.

*Re-treatment of Paget’s disease may be considered in patients who have relapsed, based on increases in serum phosphatase, or in patients who fail to achieve normalization of serum alkaline phosphatase, or in patients with symptoms as dictated by current standard medical practice.

Zometa®

HCPCS code J3487, injection, zoledronic acid, (Zometa) 1 mg should not be billed on the same claim as J3488. Zometa® is indicated for the following indications:

Hypercalcemia of malignancy

Re-treamtent of Hypercalcemia of malignancey – repeat one dose, of Zometa after a minimum of 7 days following the initial dose

Bone metastisis from solid tumors in conjuction with standard antineoplastic therapy including bones metastases from multiple myeloma, breast carcimona, prostate carcinoma, and other solid tumors

The number of units billed on a claim should be 4 since Zometa is given as a single 4 mg injection

The off-labeled indication for the use of Zometa® should be billed as follows:

Drug induced osteopenia, secondary to androgen-depravation therapy in prostate cancer patients (prophylaxis) ICD-9-CM code

733.90 Disorder of bone and cartilage, unspecified.

Monoclonal Antibodies - RANK ligand (RANKL) Inhibitors:

Prolia™

Part A providers should report denosumab injection, 1 mg, (Prolia™) using HCPCS code J0897 for the treatment of postmenopausal osteoporosis

CPT code 96401 (Chemotherapy administration, subcutaneous or intramuscular; non-hormonal antineoplastic) can be used for the administration of Prolia™

Prolia is only given twice a year, so, there should only be two claims submitted per 12 months. Know more about Prolia.

Xgeva™

Part B providers should report denosumab (Xgeva™) using HCPCS code J0897 for the prevention of skeletal-related events in patients with bone metastisis from solid tumors.

CPT code 96401 (Chemotherapy administration, subcutaneous or intramuscular; non-hormonal antineoplastic) can be used for the administration of Xgeva™.

The number of units billed on a claim should be 120 since the dosage of Xgeva™ is 120 mg every four weeks for this indication.

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