TPG-HC’s strategic alliance with Pro Pharma Pharmaceutical Consultants allows us to work jointly with clients to provide expertise, tools and resources to assist your organization in the Prior Authorization process. Read more from Pro Pharma on the latest developments impacting prior authorizations.

On a daily basis we are asked about medications that are covered under Medicare Part B and billed under medical benefits. Medications requiring Prior Authorization (PA) include specialty medications, as well as, adjunctive and symptomatic therapy. Often therapies are denied based on information provided in the claim, and just as often the incorrect HCPCS codes are used for the adjunctive therapies.

The following comments are meant to provide some instructions, clarity and recommendations to improve the billing and payment of medications under the medical benefit. These comments are based on our experience, results of audits and analyses, as well as, coding errors.

Why do Prior Authorizations get rejected?
There are several reasons for a Prior Authorization to be rejected, including excessive quantity, off-label use, or simply citing a diagnosis which is not approved for that diagnosis, among others, as listed below.

Prior Authorization Rejection Reasons:

  1. Missing or Invalid Provider ID
  2. Missing or Invalid Drug Name
  3. Missing or Invalid Billing Code
  4. Missing or Invalid NDC
  5. Missing Prior Auth Number
  6. Missing or Invalid Dates of Service
  7. Incorrect Quantity for Dates of Service
  8. Service Is Not Consistent With or Not Covered For This Diagnosis Code
  9. Epogen Units Exceeded
  10. Missing, Incomplete, or Invalid Drug Name, Strength or Dosage
  11. Drug Invalid for Gender or Age of Patient
  12. Missing or Invalid ICD-10
  13. Concomitant Therapy or Drug Interaction Question
  14. Non-Medication Items and Supplies
  15. Combination Treatment Not Approved
  16. Further Patient Information Is Required
  17. Non-Billable ICD-10 Code

Common Mistake: Chemotherapy Educed Nausea or Vomiting
We have noticed a pattern in the Prior Authorizations, in which malignant neoplasm is being cited when requesting medication(s) which are approved for chemotherapy induced nausea (Table 2). For your benefit, we have included a table below which lists appropriate ICD-10 codes (Table 1) for these cases, as an example.

Please note these should be the secondary diagnosis, the primary being Neoplasm.

Table 1

ICD10 Description
R11.2 Nausea with vomiting; unspecified
R11.0 Nausea
R11.10 Vomiting, unspecified
R11.11 Vomiting without nausea
R11.12 Projectile vomiting


Table 2

JCode Description
J1260 Dolasetron mesylate, 10 mg, injection
J1626 Granisetron hydrochloride, 100 mcg, injection
J2405 Ondansetron HCI, per 1 mg, injection
J2469 Palonosetron HCI, 25 mcg, inj.
Q0162 Ondansetron 1 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen
Q0166 Granisetron HCI, 1 mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 24-hour dosage regimen
S0091 Granisetron hydrochloride, 1 mg, Inj. (for circumstances falling under the Medicare statute, use Q0166)
S0119 Ondansetron, oral, 4 mg (for circumstances falling under the Medicare Statute, use Q0162)
S0174 Dolasetron mesylate, oral, 50 mg (for circumstances falling under Medicare statute, use Q0180.)


Prior Authorizations can serve as a great tool to ensure that the proper course of treatment is given but oftentimes it is seen as a roadblock to treatment. By educating all healthcare professionals involved in the process, more Prior Authorizations may be properly completed, submitted and approved.


Reprinted with the permission of Pro Pharma Pharmaceutical Consultants, Inc. Pharmacy Benefit News (PBN). Please call Pro Pharma with any questions and/or clarification at (888) 701-5438.