Self-Administered Drug Exclusion List - R20, Effective April 5, 2021

This coverage article has been revised and published for notice under contract numbers: 01112 (NCA), 01182 (SCA), 01212 (AS, GU, HI, NMI), and 01312 (NV).

Effective Date: 04/05/2021
Summary of Changes: The article is updated to add: J0129 (Orencia®, subcutaneous use*), C9399.J3490 and J3590 Sogroya® (somapacitan-beco), effective 4/5/2021.

Removed the following drug to the Non-Excluded CPT/HCPCS Codes - Table Format: C9399 and J3590, Zinbryta (daclizumab), effective 2/18/2021. This drug was taken of the market.

J2354 has been updated to add asterisk criteria in the "Descriptor Brand Name" section.

Added the following in Article Guidance:

Route of Administration Modifier

The use of the JA and JB modifiers is required for drugs which have one HCPCS Level II (J or Q) code but multiple routes of administration. Drugs that fall under this category will be marked with an asterisk (*) and must be billed with JA modifier for the intravenous infusion of the drug or billed with the JB modifier for subcutaneous injection of the drug. Claims billed with the JA modifier are not part of the SAD exclusion. The Contractor will process claims with the JA modifier applying the policy that not only the drug is medically reasonable and necessary, but also that the route of administration is medically reasonable and necessary. Claims for drugs marked with an asterisk (*) billed without a JA or JB modifier will be denied.

CPT/HCPCS Modifiers

Group 1 Paragraph: Claim denials may occur when the appropriate modifier is not applied to a J code/medication, which has more than one route off administration.
Group 1 Codes:
JA - Intravenous administration
JB - Subcutaneous administration

Added a notice at the beginning of the article:

Noridian decided to defer additions to the Usually Self-Administered Drug (USAD) list at the start of the public health emergency (PHE) to decrease potential patient care burden. The PHE has now lasted nearly one year and will likely continue for some time. With this notice we will begin to add drugs to the USAD list when appropriate which may facilitate the ability of patients to self-inject and avoid further trips to offices and facilities and potential Covid-19 exposure.

Visit the Self-Administered Drugs (SADs) webpage to view the locally hosted Self-Administered Drug Exclusion List.

To view the complete listing of locally hosted coverage articles and/or access the Active, Future, or Retired articles available in the CMS MCD, visit the Medicare Coverage Articles webpage.


            Last Updated Thu, 18 Feb 2021 20:42:54 +0000