Drugs and Biologicals Denials

Published 07/09/2020

Due to the high cost of biologicals and the increasing utilization trends, several drugs were identified for review during this option year.

Drugs selected are categorized as a Major Risk per the Part A/B Prioritization Report and are the top drugs based on dollars at risk and CERT error rates. Outpatient services ranks fourth on the CERT Improper Payment report with an improper payment of $299,661,709 and a projected improper error rate of 9.5 percent.

Pegfilgrastim (Neulasta®) is the highest ranked drug on the list of Major Risk drugs for Part A Outpatient bill type 13X, with total potential dollars at risk of $35,781,453. Denosumab (Prolia®) has total potential dollars at risk of $28,626,756 and Bevacizumab (Avastin®) has potential dollars at risk of $27,803,356.

Currently J2505-Pegfilgrastim (Neulasta®) 6mg, J0897-Denosumab® (Prolia)Injection 1 mg, J9035-Bevacizumab (Avastin®) 10mg, Infliximab (Remicade®) 10mg and J9310/J9312- Rituximab, 100 mg/Rituximab, 10 mg are under Medical Review for Part A.

Other J codes that Medical Review may potentially review include; J9271-Pembrolizumab (Keytruda®), J9299-Nivolumab (Opdivo®), J2350-Ocrelizumab (Ocrevus®), 1 mg and, J1459- IVIG (Privigen®) 500 mg.
Below are denials commonly seen for these drugs. Please click the denial code for the code explanation and ways to prevent the denial.

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