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Make sure you have everything you need for an appeal by downloading an Appeals checklist in the Forms and Documents.
|174.0 – 174.9||Malignant neoplasm of female breast|
|175.0 - 175.9||Malignant neoplasm of male breast|
|Drug: HCPCS†||J9306||Injection, pertuzumab, 1 mg|
|Hospital Outpatient: HCPCS||C9292||Injection, pertuzumab, 10 mg|
|50242-145-01||50242-0145-01||420 mg/14 mL single-use vial|
|Select Services, Procedures and Supplies: CPT®||||96413||Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug|
|96415||Chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition to code for primary procedure)|
|96417||Chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/drug), up to 1 hour (List separately in addition to code for primary procedure)|
|*||International Classification of Diseases, 9th Revision, Clinical Modification.|
|†||Healthcare Common Procedure Coding System.|
|‡||National Drug Code.|
|§||Payer requirements regarding use of a 10-digit or 11-digit NDC may vary. Both formats are listed here for your reference. PERJETA Access Solutions provides this information when we perform a benefits investigation (BI) for your patient.|
|||||Current Procedural Terminology.|
This table is provided for informational purposes only. Correct coding is the responsibility of the provider submitting the claim for the item or service. Please check with the payer to verify codes and special billing requirements. Genentech does not make any representation or guarantees concerning reimbursement or coverage for any service or item.
When a physician, hospital or other provider or supplier must discard the remainder of a single-use vial or other single-use package after administering a dose/quantity of the drug or biological to a Medicare patient, the program provides payment for the amount of drug or biological discarded as well as the dose administered, up to the amount of the drug or biological as indicated on the vial or package label.
Regarding billing for unused portions of multi-use vials, please NOTE: Multi-use vials are not subject to payment for discarded amounts of drug or biological.
|Please visit CMS.gov or other payers’ websites to obtain additional guidance on their processes related to billing and coding for single-use vials and wastage.|
If your office has prescribed PERJETA, but your patient’s insurer has denied coverage, you can appeal that decision. PERJETA Access Solutions might be able to help you as you resolve the situation. Here is what you can do*:
|Q:||How long does the member or doctor’s office have to file an appeal or grievance?|
|A:||You or your patient may appeal a denial of a benefit or service in writing within a period as short as 15 days or sometimes up to 180 days or more. Check with the insurer to determine its guidelines.|
|Q:||Who is responsible for sending the appeal directly to the patient’s health care plan?|
|A:||The patient or the doctor’s office is responsible for reviewing, approving and sending the appeals package to the insurer.|
|*||This description of the appeals process is for informational purposes only. The submission of an appeal is the responsibility of the patient and your office. PERJETA Access Solutions makes no representation or guarantee concerning reimbursement or coverage for any service or item. Each health insurer and patient case may require different information. Please review each denial and the health insurer’s guidelines to determine what to include in your patient’s appeal package.|