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Medically Unlikely Edits (MUE)
Daily billing-unit limits for HCPCS drug codes
Overview
A Medically Unlikely Edit (MUE) is the maximum units of service a provider would report for a HCPCS/CPT code for a single patient on a single date of service under most circumstances. CMS publishes the edits as part of the National Correct Coding Initiative, and Medicare contractors apply them automatically: billing above the limit denies the whole claim line, most often as denial code CO-151, before anyone reviews the claim. Commercial payers commonly apply the same limits.
The table below lists the 1,193 drug codes that carry a published MUE, in both care settings. CMS does not publish an edit for every HCPCS drug code, so a code absent from this table has no MUE on the current CMS file rather than an unlimited one. 187 codes carry a different limit in the practitioner office than in the hospital outpatient department, so both columns matter. Each code links to its drug page for pricing, NDC packages, and billing detail, and each row expands to show the CMS rationale behind the limit.
187 codes with different office vs hospital limits
108 / 98 codes not payable in the office / in hospital outpatient
151 codes capped at a single billing unit per day
54% of limits come straight from the drug's prescribing information
How to read this table
Billing unit: the HCPCS unit of measure. Units billed are the dose
divided by this amount, rounded up.
MAI 1: a line-level edit; the limit applies per claim line and
medically necessary units beyond it can be reported on separate lines with the
correct modifiers.
MAI 2: absolute date-of-service edit; policy-based, never
exceeded.
MAI 3: clinical date-of-service edit; may be overridden with
documentation on appeal.
Not payable: an MUE of 0. CMS uses zero where the code is
invalid, bundled, excluded, or otherwise not payable in that setting.
No published MUE: CMS keeps this value confidential. It is still
applied to claims; it does not mean "no limit".
Check a Dose Against the Limit
Pick a drug, enter the dose administered, and see whether the day's billing units clear the published MUE, and what your options are if they don't.
Billing units round up to the next whole unit, and discarded single-dose-vial amounts billed with modifier JW count toward the day's units too. Informational only; confirm against the current CMS files and your payer's policy before billing.
Result
Enter a drug or HCPCS code and the dose administered to compare the day's billing units against the published MUE.
MUE Values for HCPCS Drug Codes
Each value is the most billing units payable for one patient in a single day in that care setting; the grey figure beneath translates it into the drug's own units. CMS published values effective July 1, 2026.
| HCPCS Code | Drug | Billing Unit 1 unit equals | Practitioner Office max units per day | Hospital Outpatient max units per day | Edit Type how it's enforced | Rationale |
|---|---|---|---|---|---|---|
| 90371 | Hyperhep B | 1 ml | 10= 10 ml/day | 10= 10 ml/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| 90375 | Hyperrab | 150 iu | 20= 3,000 iu/day | 20= 3,000 iu/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| 90376 | Imogam Rabies-Ht | 150 iu | 20= 3,000 iu/day | 20= 3,000 iu/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| 90377 | Kedrab | 150 iu | 20= 3,000 iu/day | 20= 3,000 iu/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| 90378 | Synagis | 50mg | 4= 200 mg/day | 4= 200 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| 90380 | Beyfortus | 0.5 ml | 1= 0.5 ml/day | 1= 0.5 ml/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90381 | Beyfortus | 1 ml | 2= 2 ml/day | 2= 2 ml/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90396 | Varizig | 125 iu | 1= 125 iu/day | 1= 125 iu/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90585 | Bcg (Tice Strain) | 50 mg | 1= 50 mg/day | 1= 50 mg/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90586 | Bcg (Tice Strain) | 1 each | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90587 | Dengvaxia | per dose | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90593 | Vimkunya | per dose | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90619 | Menquadfi | per dose | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90620 | Bexsero | per dose | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90621 | Trumenba | per dose | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90623 | Penbraya | per dose | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90624 | Penmenvy | per dose | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90632 | Havrix | 1 ml | 1= 1 ml/day | 1= 1 ml/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90633 | Havrix Pediatric | per dose | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90636 | Twinrix | per dose | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90647 | Pedvaxhib | per dose | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90648 | Acthib | per dose | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90651 | Gardasil 9 | per dose | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90653 | Fluad Trivalent (2024/2025) Preservative Free | 0.5 ml | 1= 0.5 ml/day | 1= 0.5 ml/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90655 | Afluria Preservative Free | per dose | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90656 | Fluvarix Trivalent (2024/2025) Preservative Free | 0.5 ml | 1= 0.5 ml/day | 1= 0.5 ml/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90657 | Fluzone High-Dose (2024/2025) Preservative Free | 0.25 ml | 1= 0.25 ml/day | 1= 0.25 ml/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90658 | Fluzone High-Dose (2024/2025) Preservative Free | 0.5 ml | 1= 0.5 ml/day | 1= 0.5 ml/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90660 | Flumist Quadrivalent (2023/2024) | 0.2 ml | 1= 0.2 ml/day | 1= 0.2 ml/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90661 | Flucelvax Trivalent (2024/2025) | 0.5 ml | 1= 0.5 ml/day | 1= 0.5 ml/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90662 | Fluzone High-Dose Quadrivalent (2020/2021) | 0.5 ml | 1= 0.5 ml/day | 1= 0.5 ml/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90670 | Prevnar - 13 | 0.5 ml | 1= 0.5 ml/day | 1= 0.5 ml/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90671 | Vaxneuvance | 1 ea | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90672 | FluMist Quadrivalent (2021/2022) | 0.2 ml | 1= 0.2 ml/day | 1= 0.2 ml/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90673 | Afluria Trivalent (2024/2025) | 0.5 ml | 1= 0.5 ml/day | 1= 0.5 ml/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90674 | Flucelvax Quadrivalent 2022-2023 Formula Pf | 0.5 ml | 1= 0.5 ml/day | 1= 0.5 ml/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90675 | Imovax Rabies | 1 ml | 1= 1 ml/day | 1= 1 ml/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90677 | Prevnar 20 | 1 ea | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90678 | Abrysvo | per dose | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90679 | Arexvy | per dose | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90680 | Rotateq | per dose | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90681 | Rotarix | per dose | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90682 | Flublok Quadrivalent 2022-2023 Formula | 0.5 ml | 1= 0.5 ml/day | 1= 0.5 ml/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90683 | Mresvia | per dose | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90684 | Capvaxive | 1 ea | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90685 | Afluria Quadrivalent 2023-2024 Formula Pf | 0.25 ml | 1= 0.25 ml/day | 1= 0.25 ml/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90686 | Fluarix Quadrivalent (2021/2022) (Pres free) | 0.5 ml | 1= 0.5 ml/day | 1= 0.5 ml/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90687 | Afluria Quadrivalent 0.25ML (2019/2020) | 0.25 ml | 1= 0.25 ml/day | 1= 0.25 ml/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90688 | Flulaval Quadrivalent (2019/2020) | 0.5 ml | 1= 0.5 ml/day | 1= 0.5 ml/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90690 | Vivotif | per dose | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90691 | Typhim Vi | per dose | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90694 | Fluad Quadrivalent 2022-2023 Formula | 0.5 ml | 1= 0.5 ml/day | 1= 0.5 ml/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90696 | Quadracel | per dose | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90697 | Vaxelis | per dose | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90698 | Pentacel | per dose | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90700 | Daptacel | per dose | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90702 | Diphtheria And Tetanus Toxoids Adsorbed | #n/a | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90707 | M-M-R Ii | per dose | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90710 | Proquad | per dose | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90713 | Ipol | per dose | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90714 | Tdvax | 0.5 ml | 1= 0.5 ml/day | 1= 0.5 ml/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90715 | Adacel Tdap | 0.5 ml | 1= 0.5 ml/day | 1= 0.5 ml/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90716 | Varivax | per dose | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90717 | Yf-Vax | per dose | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90723 | Pediarix | per dose | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| 90732 | Pneumovax 23 | 0.5 ml | 1= 0.5 ml/day | 1= 0.5 ml/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90734 | Menactra | per dose | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90738 | Ixiaro | per dose | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90739 | Heplisav-B | 1 dose | 1= 1 dose/day | 1= 1 dose/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90740 | Engerix-B | 40 mcg | 1= 40 mcg/day | 1= 40 mcg/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90743 | Recombivax Hb | 1 dose | 1= 1 dose/day | 1= 1 dose/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90744 | Engerix-B Pediatric | 1 dose | 1= 1 dose/day | 1= 1 dose/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90746 | Engerix-B | 1 dose | 1= 1 dose/day | 1= 1 dose/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90747 | Engerix-B | 40 mcg | 1= 40 mcg/day | 1= 40 mcg/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90756 | Flucelvax Quadrivalent (2021/2022) | 0.5 ml | 1= 0.5 ml/day | 1= 0.5 ml/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 90759 | Prehevbrio | 10 mcg | 1= 10 mcg/day | 1= 10 mcg/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 91304 | Novavax Covid-19 Vaccine, 2023-2024 Adjuvanted | 0.5 ml | 1= 0.5 ml/day | 1= 0.5 ml/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 91318 | Covid-19 Vaccine 2023-2024 | 0.3 ml | 1= 0.3 ml/day | 1= 0.3 ml/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 91319 | Pfizer-Biontech Covid-19 Vaccine 2023-2024 Age5<12 | 0.3 ml | 1= 0.3 ml/day | 1= 0.3 ml/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 91320 | Comirnaty 2023-2024 Age 12 And Older | 0.3 ml | 1= 0.3 ml/day | 1= 0.3 ml/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 91321 | Covid-19 Vaccine 2023-2024 | 0.25 ml | 1= 0.25 ml/day | 1= 0.25 ml/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| 91322 | Spikevax 2023-2024 Formula | 0.5 ml | 1= 0.5 ml/day | 1= 0.5 ml/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| A4216 | Sodium Chloride Flush | 10 ml | 0 — not payable | 25= 250 ml/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: CMS Policy. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: CMS Workgroup. | ||||||
| A9500 | Technetium Tc 99M Sestamibi | per study dose | 3 | 3 | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Society Comment | ||||||
| A9502 | Myoview | per study dose | 3 | 3 | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Society Comment | ||||||
| A9506 | Technegas | each | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| A9512 | TechneLite | per millicurie | 30 | 30 | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| A9513 | Lutathera | 1 mci | 200= 200 mci/day | 200= 200 mci/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| A9520 | Lymphoseek | 0.5 millicuries | 1= 0.5 millicuries/day | 1= 0.5 millicuries/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Society Comment | ||||||
| A9521 | Ceretec | up to 25 millicuries | 2 | 2 | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Code Descriptor / CPT Instruction | ||||||
| A9537 | Technetium Tc 99M Mebrofenin | up to 15 millicuries | 1 | 1 | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Code Descriptor / CPT Instruction | ||||||
| A9543 | Zevalin | up to 40 millicuries | 1 | 1 | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Code Descriptor / CPT Instruction | ||||||
| A9547 | Indium In 111 Oxyquinoline | 0.5 millicuries | 2= 1 millicuries/day | 2= 1 millicuries/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| A9548 | Indium In 111 DTPA | 0.5 millicuries | 2= 1 millicuries/day | 2= 1 millicuries/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| A9573 | Elucirem | 1 ml | 18= 18 ml/day | 18= 18 ml/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| A9575 | Clariscan | 0.1 ml | 300= 30 ml/day | 300= 30 ml/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| A9576 | Prohance Multipack | 1 ml | 100= 100 ml/day | 100= 100 ml/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| A9577 | Multihance | 1 ml | 50= 50 ml/day | 50= 50 ml/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| A9578 | Multihance Multipack | 1 ml | 50= 50 ml/day | 50= 50 ml/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| A9579 | Omniscan | 1 ml | 100= 100 ml/day | 100= 100 ml/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| A9581 | Eovist | 1 ml | 20= 20 ml/day | 20= 20 ml/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| A9582 | Adreview | up to 15 millicuries | 1 | 1 | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Code Descriptor / CPT Instruction | ||||||
| A9584 | Datscan | per study dose, up to 5 millicuries | 1 | 1 | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Code Descriptor / CPT Instruction | ||||||
| A9585 | Gadavist | 0.1 ml | 300= 30 ml/day | 300= 30 ml/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| A9586 | Amyvid | up to 10 mci | 1 | 1 | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Code Descriptor / CPT Instruction | ||||||
| A9587 | Netspot | 0.1 mci | 54= 5.4 mci/day | 54= 5.4 mci/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| A9588 | Axumin | 1 mci | 10= 10 mci/day | 10= 10 mci/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| A9589 | Cysview | 100 mg | 1= 100 mg/day | 1= 100 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| A9590 | — | — | 675 | 675 | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| A9591 | Cerianna | 1 mci | 6= 6 mci/day | 6= 6 mci/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| A9592 | Detectnet | 1 mci | 4= 4 mci/day | 4= 4 mci/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| A9595 | Pylarify | 1 millicurie | 10= 10 millicurie/day | 10= 10 millicurie/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| A9596 | Illuccix | 1 mci | 7= 7 mci/day | 7= 7 mci/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| A9600 | Strontium Chloride Sr 89 | per millicurie | 7 | 7 | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| A9601 | Tauvid | 1 mci | 10= 10 mci/day | 10= 10 mci/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| A9602 | Fluorodopa F18 | 1 mci | 5= 5 mci/day | 5= 5 mci/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| A9604 | Quadramet | up to 150 millicuries | 1 | 1 | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Code Descriptor / CPT Instruction | ||||||
| A9606 | Xofigo | 1 mci | 224= 224 mci/day | 224= 224 mci/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| A9607 | Pluvicto | 1 mci | 216= 216 mci/day | 216= 216 mci/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| A9608 | Posluma | 1 mci | 8= 8 mci/day | 8= 8 mci/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| A9609 | Fludeoxyglucose F18 | 15 millicuries | 1= 15 millicuries/day | 1= 15 millicuries/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Code Descriptor / CPT Instruction | ||||||
| A9611 | Flyrcado | 1 mci | 13= 13 mci/day | 13= 13 mci/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| A9615 | Lumisight | 1 mg | 156= 156 mg/day | 156= 156 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| A9800 | Locametz | 1 mci | 7= 7 mci/day | 7= 7 mci/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| C9046 | Cocaine Hcl | 1 mg | 160= 160 mg/day | 160= 160 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| C9047 | Cablivi | 1 mg | 22= 22 mg/day | 22= 22 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| C9101 | Olinvyk | 0.1 mg | 300= 30 mg/day | 300= 30 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| C9143 | Numbrino | 1 mg | 160= 160 mg/day | 160= 160 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| C9144 | Posimir | 1 mg | 660= 660 mg/day | 660= 660 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| C9250 | Artiss | 2 ml | 1= 2 ml/day | 5= 10 ml/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| C9254 | Vimpat | 1 mg | 400= 400 mg/day | 400= 400 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: CMS Workgroup. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| C9257 | Avastin | 0.25 mg | 10= 2.5 mg/day | 10= 2.5 mg/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Anatomic Consideration | ||||||
| C9293 | Voraxaze | 10 units | 700= 7,000 units/day | 700= 7,000 units/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| C9460 | Kengreal | 1 mg | 1= 1 mg/day | 100= 100 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: CMS Workgroup. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| C9462 | Baxdela | 1 mg | 600= 600 mg/day | 600= 600 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| C9482 | Sotalol Hcl | 1 mg | 150= 150 mg/day | 300= 300 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| C9488 | Vaprisol-5% Dextrose | 1 mg | 20= 20 mg/day | 40= 40 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| C9507 | — | — | 2 | 2 | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Code Descriptor / CPT Instruction | ||||||
| J0120 | Tetracycline Hcl | 250 mg | 1= 250 mg/day | 1= 250 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J0121 | Nuzyra | 1 mg | 200= 200 mg/day | 200= 200 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0122 | Xerava | 1 mg | 300= 300 mg/day | 300= 300 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0129 | Orencia | 10 mg | 100= 1,000 mg/day | 100= 1,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0130 | Abciximab | 10 mg | 4= 40 mg/day | 6= 60 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| J0131 | Ofirmev | 10 mg | 400= 4,000 mg/day | 400= 4,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0132 | Acetadote | 100 mg | 12= 1,200 mg/day | 300= 30,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J0133 | Acyclovir Sodium | 5 mg | 1,200= 6,000 mg/day | 1,200= 6,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0134 | Acetaminophen | 10 mg | 400= 4,000 mg/day | 400= 4,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0136 | Acetaminophen | 10 mg | 400= 4,000 mg/day | 400= 4,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0137 | Acetaminophen | 10 mg | 400= 4,000 mg/day | 400= 4,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0138 | Combogesic | 10 mg/3mg | 400= 4,000 mg/3mg/day | 400= 4,000 mg/3mg/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| J0139 | Humira | 1 mg | 160= 160 mg/day | 160= 160 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: CMS Policy. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| J0153 | Adenocard | 1 mg | 180= 180 mg/day | 180= 180 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0165 | Epinephrine Hcl | 0.1 mg | 20= 2 mg/day | 120= 12 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0166 | Epinephrine Hcl (Belcher) | 0.1 mg | 20= 2 mg/day | 120= 12 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0167 | Epinephrine Hcl | 0.1 mg | 20= 2 mg/day | 120= 12 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0168 | Epinephrine Hcl | 0.1 mg | 20= 2 mg/day | 120= 12 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0169 | Adrenalin | 0.1 mg | 20= 2 mg/day | 120= 12 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0175 | Kisunla | 2 mg | 700= 1,400 mg/day | 700= 1,400 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0177 | Eylea Hd | 1 mg | 16= 16 mg/day | 16= 16 mg/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Anatomic Consideration | ||||||
| J0178 | Eylea | 1 mg | 4= 4 mg/day | 4= 4 mg/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Anatomic Consideration | ||||||
| J0179 | Beovu | 1 mg | 12= 12 mg/day | 12= 12 mg/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Anatomic Consideration | ||||||
| J0180 | Fabrazyme | 1 mg | 140= 140 mg/day | 140= 140 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J0184 | Barhemsys | 1 mg | 10= 10 mg/day | 10= 10 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0185 | Cinvanti | 1 mg | 130= 130 mg/day | 130= 130 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0202 | Lemtrada | 1 mg | 12= 12 mg/day | 12= 12 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0206 | Allopurinol | 1 mg | 1,000= 1,000 mg/day | 1,000= 1,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0207 | Ethyol | 500 mg | 4= 2,000 mg/day | 4= 2,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J0208 | Sodium Thiosulfate | 100 mg | 500= 50,000 mg/day | 500= 50,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0209 | Sodium Thiosulfate | 100 mg | 250= 25,000 mg/day | 250= 25,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J0210 | Methyldopate Hcl | 250 mg | 4= 1,000 mg/day | 16= 4,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0211 | Nithiodote | 3 mg and 125 mg | 200= 600 mg and 125 mg/day | 200= 600 mg and 125 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J0217 | Lamzede | 1 mg | 150= 150 mg/day | 150= 150 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0218 | Xenpozyme | 1 mg | 460= 460 mg/day | 460= 460 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J0219 | Nexviazyme | 4 mg | 750= 3,000 mg/day | 750= 3,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0220 | Alglucosidase Alfa | 10 mg | 1= 10 mg/day | 20= 200 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| J0221 | Lumizyme | 10 mg | 250= 2,500 mg/day | 300= 3,000 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| J0222 | Onpattro | 0.1 mg | 300= 30 mg/day | 300= 30 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0223 | Givlaari | 0.5 mg | 756= 378 mg/day | 756= 378 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J0224 | Oxlumo | 0.5 mg | 945= 472.5 mg/day | 945= 472.5 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J0225 | Amvuttra | 1 mg | 25= 25 mg/day | 25= 25 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0248 | Veklury | 1 mg | 200= 200 mg/day | 200= 200 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0256 | Aralast Np | 10 mg | 1,600= 16,000 mg/day | 1,600= 16,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J0257 | Glassia | 10 mg | 1,400= 14,000 mg/day | 1,400= 14,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J0270 | Prostin Vr Pediatric | 1.25 mcg | 32= 40 mcg/day | 32= 40 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J0278 | Amikacin Sulfate | 100 mg | 15= 1,500 mg/day | 15= 1,500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0280 | Aminophylline | 250 mg | 7= 1,750 mg/day | 10= 2,500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0281 | Aminocaproic Acid | 1 gm | 30= 30 gm/day | 30= 30 gm/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0282 | Amiodarone Hcl | 30 mg | 35= 1,050 mg/day | 70= 2,100 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. | ||||||
| J0283 | Nexterone | 30 mg | 35= 1,050 mg/day | 70= 2,100 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. | ||||||
| J0285 | Amphotericin B | 50 mg | 5= 250 mg/day | 5= 250 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0287 | Abelcet | 10 mg | 50= 500 mg/day | 60= 600 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J0289 | Ambisome | 10 mg | 50= 500 mg/day | 115= 1,150 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| J0290 | Ampicillin | 500 mg | 24= 12,000 mg/day | 24= 12,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J0291 | Zemdri | 5 mg | 500= 2,500 mg/day | 500= 2,500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J0295 | Ampicillin-Sulbactam | 1.5 gm | 12= 18 gm/day | 12= 18 gm/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J0300 | Amytal Sodium | 125 mg | 8= 1,000 mg/day | 8= 1,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0330 | Succinylcholine Chloride | 20 mg | 10= 200 mg/day | 50= 1,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J0348 | Eraxis (Water Diluent) | 1 mg | 200= 200 mg/day | 200= 200 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0349 | Rezzayo | 1 mg | 400= 400 mg/day | 400= 400 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0360 | Hydralazine Hcl | 20 mg | 2= 40 mg/day | 6= 120 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0364 | Apokyn | 1 mg | 6= 6 mg/day | 6= 6 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0390 | Chloroquine Hydrochloride | 250 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Drug discontinued | ||||||
| J0391 | Artesunate | 1 mg | 770= 770 mg/day | 770= 770 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J0400 | Aripiprazole | 0.25 mg | 39= 9.75 mg/day | 120= 30 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0401 | Abilify Maintena | 1 mg | 400= 400 mg/day | 400= 400 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0402 | Abilify Asimtufii | 1 mg | 960= 960 mg/day | 960= 960 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0456 | Azithromycin | 500 mg | 4= 2,000 mg/day | 4= 2,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0457 | Aztreonam | 100 mg | 80= 8,000 mg/day | 80= 8,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0461 | Atropine Sulfate | 0.01 mg | 200= 2 mg/day | 800= 8 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J0470 | Bal In Oil | 100 mg | 2= 200 mg/day | 2= 200 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J0475 | Baclofen | 10 mg | 8= 80 mg/day | 8= 80 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0476 | Baclofen | 50 mcg | 2= 100 mcg/day | 2= 100 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0480 | Simulect | 20 mg | 1= 20 mg/day | 1= 20 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0485 | Nulojix | 1 mg | 1,500= 1,500 mg/day | 1,500= 1,500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0490 | Benlysta | 10 mg | 160= 1,600 mg/day | 160= 1,600 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0491 | Saphnelo | 1 mg | 300= 300 mg/day | 300= 300 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0500 | Dicyclomine Hci | 20 mg | 4= 80 mg/day | 4= 80 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0515 | Benztropine Mesylate | 1 mg | 3= 3 mg/day | 6= 6 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J0517 | Fasenra | 1 mg | 30= 30 mg/day | 30= 30 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0520 | Bethanechol Chloride | 5 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Drug discontinued | ||||||
| J0558 | Bicillin C-R | 100,000 units | 24= 2,400 ,000 units/day | 24= 2,400 ,000 units/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0561 | Bicillin L-A | 100,000 units | 24= 2,400 ,000 units/day | 24= 2,400 ,000 units/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0565 | Zinplava | 10 mg | 200= 2,000 mg/day | 200= 2,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0567 | Brineura | 1 mg | 300= 300 mg/day | 300= 300 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0571 | Buprenorphine | 1 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Oral Medication; Not Payable | ||||||
| J0572 | Buprenorphine-Naloxone | 3 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Oral Medication; Not Payable | ||||||
| J0573 | Buprenorphine-Naloxone | 10 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Oral Medication; Not Payable | ||||||
| J0574 | Buprenorphine-Naloxone | 10 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Oral Medication; Not Payable | ||||||
| J0575 | Buprenorphine-Naloxone | 10 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Oral Medication; Not Payable | ||||||
| J0577 | Brixadi (Weekly Dosing) | less than or equal to 7 days of therapy | 1 | 1 | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0578 | Brixadi (Monthly Dosing) | greater than 7 days and up to 28 days of therapy | 1 | 1 | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0583 | Angiomax | 1 mg | 250= 250 mg/day | 1,250= 1,250 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J0584 | Crysvita | 1 mg | 90= 90 mg/day | 90= 90 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0585 | Botox | 1 unit | 800= 800 unit/day | 800= 800 unit/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J0586 | Dysport | 5 units | 300= 1,500 units/day | 300= 1,500 units/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0587 | Myobloc | 100 units | 300= 30,000 units/day | 300= 30,000 units/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J0588 | Xeomin | 1 unit | 600= 600 unit/day | 600= 600 unit/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J0589 | Daxxify | 1 unit | 300= 300 unit/day | 300= 300 unit/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J0591 | Doxycholic Acid | 1 mg | 100= 100 mg/day | 100= 100 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0592 | Buprenex | 0.1 mg | 6= 0.6 mg/day | 12= 1.2 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J0593 | Takhzyro | 1 mg | 300= 300 mg/day | 300= 300 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0594 | Busulfan | 1 mg | 320= 320 mg/day | 320= 320 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0595 | Butorphanol Tartrate | 1 mg | 8= 8 mg/day | 12= 12 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J0596 | Ruconest | 10 units | 840= 8,400 units/day | 840= 8,400 units/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0597 | Berinert | 10 units | 250= 2,500 units/day | 250= 2,500 units/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0598 | Cinryze | 10 units | 100= 1,000 units/day | 100= 1,000 units/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0599 | Haegarda | 10 units | 900= 9,000 units/day | 900= 9,000 units/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0600 | Calcium Disodium Versenate | 1000 mg | 3= 3,000 mg/day | 3= 3,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0606 | Parsabiv | 0.1 mg | 150= 15 mg/day | 150= 15 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0612 | Calcium Gluconate | 10 mg | 800= 8,000 mg/day | 800= 8,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J0613 | Calcium Gluconate | 10 mg | 800= 8,000 mg/day | 800= 8,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J0614 | Grafapex | 50 mg | 600= 30,000 mg/day | 600= 30,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0616 | Metoprolol Tartrate | 1 mg | 15= 15 mg/day | 15= 15 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0618 | Calcium Chloride | 2 mg | 2,000= 4,000 mg/day | 2,000= 4,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0620 | Calcium Gluceptate | 10 ml | 1= 10 ml/day | 1= 10 ml/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0630 | Miacalcin | 400 units | 1= 400 units/day | 8= 3,200 units/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0636 | Calcitriol | 0.1 mcg | 100= 10 mcg/day | 100= 10 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J0637 | Cancidas | 5 mg | 20= 100 mg/day | 20= 100 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0638 | Ilaris | 1 mg | 300= 300 mg/day | 300= 300 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0640 | Leucovorin Calcium | 50 mg | 24= 1,200 mg/day | 24= 1,200 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0641 | Fusilev | 0.5 mg | 1,200= 600 mg/day | 1,200= 600 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| J0642 | Khapzory | 0.5 mg | 1,200= 600 mg/day | 1,200= 600 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0650 | Levothyroxine Sodium | 10 mcg | 100= 1,000 mcg/day | 100= 1,000 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J0651 | Levothyroxine Sodium | 10 mcg | 100= 1,000 mcg/day | 100= 1,000 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J0652 | Levothyroxine Sodium | 10 mcg | 100= 1,000 mcg/day | 100= 1,000 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J0666 | Exparel | 1 mg | 266= 266 mg/day | 266= 266 mg/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Anatomic Consideration | ||||||
| J0668 | Zynrelef | 1 mg - 0.03 mg | 400= 400 mg - 0.03 mg/day | 400= 400 mg - 0.03 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0670 | Polocaine | 10 ml | 10= 100 ml/day | 10= 100 ml/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J0687 | Cefazolin | 500 mg | 16= 8,000 mg/day | 16= 8,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J0688 | Cefazolin | 500 mg | 16= 8,000 mg/day | 16= 8,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J0689 | Cefazolin Sodium | 500 mg | 16= 8,000 mg/day | 16= 8,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J0690 | Cefazolin | 500 mg | 16= 8,000 mg/day | 16= 8,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Society Comment | ||||||
| J0691 | Xenleta | 1 mg | 300= 300 mg/day | 300= 300 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0692 | Cefepime | 500 mg | 12= 6,000 mg/day | 12= 6,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0694 | Cefoxitin | 1 gm | 8= 8 gm/day | 12= 12 gm/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0695 | Zerbaxa | 75mg (50mg cft/25mg taz) | 60= 4,500 mg (50mg cft/25mg taz)/day | 60= 4,500 mg (50mg cft/25mg taz)/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0696 | Ceftriaxone | 250 mg | 16= 4,000 mg/day | 16= 4,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0697 | Cefuroxime Sodium | 750 mg | 4= 3,000 mg/day | 12= 9,000 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. | ||||||
| J0698 | Cefotaxime Sodium | per gm | 10 | 12 | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| J0699 | Fetroja | 10 mg | 600= 6,000 mg/day | 600= 6,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0701 | Cefepime HCL | 500 mg | 12= 6,000 mg/day | 12= 6,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0702 | Betamethasone Sod Phos-Acetate | 3 mg & 3 mg | 18= 54 mg & 3 mg/day | 20= 60 mg & 3 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J0703 | Cefepime HCL in Dextrose | 500 mg | 12= 6,000 mg/day | 12= 6,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0706 | Caffeine Citrate | 5 mg | 1= 5 mg/day | 16= 80 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| J0712 | Teflaro | 10 mg | 120= 1,200 mg/day | 180= 1,800 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0713 | Ceftazidime | 500 mg | 12= 6,000 mg/day | 12= 6,000 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| J0714 | Avycaz | .625 gm | 12= 7.5 gm/day | 12= 7.5 gm/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0716 | Anascorp | up to 120 mg | 4 | 4 | MAI 3 / 1 | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. Hospital edit Line Edit (MAI 1): Per-line limit: units are checked per claim line; medically necessary units beyond the limit may be billable on separate lines with appropriate modifiers. CMS rationale: Clinical: Data. | ||||||
| J0717 | Cimzia | 1 mg | 400= 400 mg/day | 400= 400 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0720 | Chloramphenicol Sod Succinate | 1 gm | 15= 15 gm/day | 15= 15 gm/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0725 | Chorionic Gonadotropin | 1000 units | 10= 10,000 units/day | 10= 10,000 units/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J0735 | Clonidine Hcl | 1 mg | 50= 50 mg/day | 50= 50 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0736 | Cleocin | 300 mg | 9= 2,700 mg/day | 9= 2,700 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0737 | Clindamycin Phosphate In Nacl | 300 mg | 9= 2,700 mg/day | 9= 2,700 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0739 | Apretude | 1 mg | 600= 600 mg/day | 600= 600 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0740 | Cidofovir | 375 mg | 2= 750 mg/day | 2= 750 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0741 | Cabenuva | 2 mg - 3 mg | 300= 600 mg - 3 mg/day | 300= 600 mg - 3 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0742 | Recarbrio | 4 mg-4 mg-2 mg | 500= 2,000 mg-4 mg-2 mg/day | 500= 2,000 mg-4 mg-2 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0743 | Imipenem-Cilastatin Sodium | 250 mg | 16= 4,000 mg/day | 16= 4,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0744 | Cipro Iv | 200 mg | 6= 1,200 mg/day | 8= 1,600 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0745 | Codeine Phosphate | 30 mg | 2= 60 mg/day | 8= 240 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. | ||||||
| J0759 | Cleviprex | 1 mg | 300= 300 mg/day | 300= 300 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J0770 | Colistimethate | up to 150 mg | 5 | 5 | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0775 | Xiaflex | 0.01 mg | 180= 1.8 mg/day | 180= 1.8 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J0780 | Prochlorperazine Edisylate | 10 mg | 4= 40 mg/day | 10= 100 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0791 | Adakveo | 5 mg | 160= 800 mg/day | 160= 800 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J0801 | H.P. Acthar | up to 40 units | 3 | 3 | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0802 | Purified Cortrophin Gel | up to 40 units | 3 | 3 | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0834 | Cortrosyn | 0.25 mg | 3= 0.75 mg/day | 3= 0.75 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0840 | Crofab | up to 1 gm | 6 | 18 | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: CMS Workgroup. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| J0841 | Anavip | 120 mg | 20= 2,400 mg/day | 24= 2,880 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Society Comment. | ||||||
| J0850 | Cytogam | per vial | 9 | 9 | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J0870 | Rytelo | 1 mg | 1,081= 1,081 mg/day | 1,081= 1,081 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J0872 | Daptomycin | 1 mg | 1,050= 1,050 mg/day | 1,050= 1,050 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J0873 | Daptomycin | 1 mg | 1,000= 1,000 mg/day | 1,000= 1,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J0874 | Daptomycin In Sodium Chloride | 1 mg | 1,000= 1,000 mg/day | 1,000= 1,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J0875 | Dalvance | 5 mg | 300= 1,500 mg/day | 300= 1,500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0877 | Daptomycin | 1 mg | 1,000= 1,000 mg/day | 1,000= 1,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J0878 | Cubicin Rf | 1 mg | 1,000= 1,000 mg/day | 1,000= 1,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J0879 | Korsuva | 0.1 mcg | 1,300= 130 mcg/day | 1,300= 130 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J0881 | Aranesp | 1 mcg | 500= 500 mcg/day | 500= 500 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J0882 | Aranesp | 1 mcg | 300= 300 mcg/day | 300= 300 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J0883 | Argatroban | 1 mg | 1,125= 1,125 mg/day | 1,250= 1,250 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0884 | Argatroban | 1 mg | 1,125= 1,125 mg/day | 1,250= 1,250 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0885 | Epogen | 1000 units | 60= 60,000 units/day | 60= 60,000 units/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0887 | Mircera | 1 mcg | 360= 360 mcg/day | 360= 360 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0888 | Mircera | 1 mcg | 360= 360 mcg/day | 360= 360 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0890 | Peginesatide | 0.1 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Drug discontinued | ||||||
| J0894 | Dacogen | 1 mg | 100= 100 mg/day | 100= 100 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J0895 | Deferoxamine Mesylate | 500 mg | 12= 6,000 mg/day | 12= 6,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0896 | Reblozyl | 0.25 mg | 1,100= 275 mg/day | 1,100= 275 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J0897 | Prolia | 1 mg | 120= 120 mg/day | 120= 120 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0901 | Vafseo | 1 mg | 600= 600 mg/day | 600= 600 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0911 | Defencath | taurolidine 1.35 mg and heparin sodium 100 units | 60 | 60 | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J0945 | Brompheniramine Maleate | 10 mg | 4= 40 mg/day | 4= 40 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1000 | Depo-Estradiol | 5 mg | 1= 5 mg/day | 1= 5 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1010 | Methylprednisolone Acetate | 1 mg | 160= 160 mg/day | 160= 160 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1050 | Depo-Provera | 1 mg | 1,000= 1,000 mg/day | 1,000= 1,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1071 | Depo-Testosterone | 1 mg | 400= 400 mg/day | 400= 400 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1072 | Azmiro | 1 mg | 400= 400 mg/day | 400= 400 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1095 | Dexycu | 1 mcg | 1,034= 1,034 mcg/day | 1,034= 1,034 mcg/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Anatomic Consideration | ||||||
| J1096 | Dextenza | 0.1 mg | 8= 0.8 mg/day | 8= 0.8 mg/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Anatomic Consideration | ||||||
| J1097 | Omidria | 1 ml | 4= 4 ml/day | 4= 4 ml/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1100 | Dexamethasone Sodium Phosphate | 1 mg | 120= 120 mg/day | 120= 120 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J1105 | Igalmi | 1 mcg | 360= 360 mcg/day | 360= 360 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1110 | Dihydroergotamine Mesylate | 1 mg | 3= 3 mg/day | 3= 3 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1120 | Acetazolamide | 500 mg | 2= 1,000 mg/day | 2= 1,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1130 | Diclofenac Sodium | 0.5 mg | 300= 150 mg/day | 300= 150 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1160 | Digoxin | 0.5 mg | 2= 1 mg/day | 3= 1.5 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1162 | Digifab | per vial | 1 | 10 | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| J1163 | Diltiazem Hcl | 0.5 mg | 900= 450 mg/day | 900= 450 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1165 | Phenytoin Sodium | 50 mg | 50= 2,500 mg/day | 50= 2,500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1171 | Hydromorphone Hcl | 0.1 mg | 240= 24 mg/day | 240= 24 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1180 | Dyphylline | 500 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Drug discontinued | ||||||
| J1190 | Dexrazoxane | 250 mg | 8= 2,000 mg/day | 8= 2,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1200 | Diphenhydramine Hcl | 50 mg | 8= 400 mg/day | 8= 400 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1201 | Quzyttir | 0.5 mg | 20= 10 mg/day | 20= 10 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1202 | Opfolda | 65 mg | 4= 260 mg/day | 4= 260 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1203 | Pombiliti | 5 mg | 630= 3,150 mg/day | 630= 3,150 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J1205 | Chlorothiazide Sodium | 500 mg | 4= 2,000 mg/day | 4= 2,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1212 | Rimso-50 | 50 ml | 1= 50 ml/day | 1= 50 ml/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1230 | Methadone Hcl | 10 mg | 3= 30 mg/day | 5= 50 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J1240 | Dimenhydrinate | 50 mg | 6= 300 mg/day | 6= 300 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1245 | Dipyridamole | 10 mg | 10= 100 mg/day | 10= 100 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J1250 | Dobutamine Hcl | 250 mg | 2= 500 mg/day | 4= 1,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J1260 | Anzemet | 10 mg | 2= 20 mg/day | 2= 20 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1265 | Dopamine Hcl | 40 mg | 20= 800 mg/day | 100= 4,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J1270 | Doxercalciferol | 1 mcg | 8= 8 mcg/day | 16= 16 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J1271 | Doxycycline Hyclate | 1 mg | 300= 300 mg/day | 300= 300 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1290 | Kalbitor | 1 mg | 30= 30 mg/day | 60= 60 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J1299 | Soliris | 2 mg | 600= 1,200 mg/day | 600= 1,200 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1301 | Radicava | 1 mg | 60= 60 mg/day | 60= 60 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1302 | Enjaymo | 10 mg | 770= 7,700 mg/day | 770= 7,700 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1303 | Ultomiris | 10 mg | 360= 3,600 mg/day | 360= 3,600 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1304 | Qalsody | 1 mg | 100= 100 mg/day | 100= 100 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1305 | Evkeeza | 5 mg | 480= 2,400 mg/day | 480= 2,400 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J1306 | Leqvio | 1 mg | 284= 284 mg/day | 284= 284 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1307 | Piasky | 10 mg | 170= 1,700 mg/day | 170= 1,700 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J1308 | Famotidine Premixed | 0.25 mg | 160= 40 mg/day | 160= 40 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1320 | Amitriptyline Hcl | 20 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Drug discontinued | ||||||
| J1322 | Vimizim | 1 mg | 150= 150 mg/day | 150= 150 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J1323 | Elrexfio | 1 mg | 76= 76 mg/day | 76= 76 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1324 | Fuzeon | 1 mg | 108= 108 mg/day | 0 — not payable | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: CMS Policy. | ||||||
| J1325 | Epoprostenol Sodium | 0.5 mg | 1= 0.5 mg/day | 18= 9 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J1326 | Vyloy | 2 mg | 1,200= 2,400 mg/day | 1,200= 2,400 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1327 | Eptifibatide | 5 mg | 1= 5 mg/day | 99= 495 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1335 | Ertapenem | 500 mg | 2= 1,000 mg/day | 2= 1,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1364 | Erythrocin Lactobionate | 500 mg | 2= 1,000 mg/day | 8= 4,000 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| J1380 | Delestrogen | 10 mg | 4= 40 mg/day | 4= 40 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1410 | Premarin | 25 mg | 4= 100 mg/day | 4= 100 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J1411 | Hemgenix | per therapeutic dose | 1 | 1 | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1412 | Roctavian | 1 ml | 456= 456 ml/day | 456= 456 ml/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J1413 | Elevidys | per therapeutic dose | 1 | 1 | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1414 | Beqvez | per therapeutic dose | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| J1426 | Amondys-45 | 10 mg | 450= 4,500 mg/day | 450= 4,500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1427 | Viltepso | 10 mg | 1,200= 12,000 mg/day | 1,200= 12,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1428 | Exondys-51 | 10 mg | 450= 4,500 mg/day | 450= 4,500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1429 | Vyondys-53 | 10 mg | 450= 4,500 mg/day | 450= 4,500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1430 | Ethamolin | 100 mg | 10= 1,000 mg/day | 10= 1,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1434 | Focinvez | 1 mg | 150= 150 mg/day | 150= 150 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1435 | Estrone | 1 mg | 1= 1 mg/day | 0 — not payable | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: CMS Policy. | ||||||
| J1436 | Etidronate Disodium | 300 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Drug discontinued | ||||||
| J1437 | Monoferric | 10 mg | 100= 1,000 mg/day | 100= 1,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1438 | Enbrel | 25 mg | 2= 50 mg/day | 2= 50 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1439 | Injectafer | 1 mg | 1,000= 1,000 mg/day | 1,000= 1,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1440 | Rebyota | 1 ml | 150= 150 ml/day | 150= 150 ml/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1442 | Neupogen | 1 mcg | 1,500= 1,500 mcg/day | 1,500= 1,500 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: CMS Workgroup | ||||||
| J1447 | Granix | 1 mcg | 960= 960 mcg/day | 960= 960 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J1448 | Cosela | 1 mg | 900= 900 mg/day | 900= 900 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J1449 | Rolvedon | 0.1 mg | 132= 13.2 mg/day | 132= 13.2 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1450 | Fluconazole In Sodium Chloride | 200 mg | 4= 800 mg/day | 4= 800 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| J1451 | Fomepizole | 15 mg | 1= 15 mg/day | 200= 3,000 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| J1453 | Emend | 1 mg | 150= 150 mg/day | 150= 150 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1454 | Akynzeo | 0.25 mg | 1= 0.25 mg/day | 1= 0.25 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1455 | Foscarnet Sodium | 1000 mg | 18= 18,000 mg/day | 18= 18,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J1456 | Fosaprepitant | 1 mg | 150= 150 mg/day | 150= 150 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1458 | Naglazyme | 1 mg | 100= 100 mg/day | 100= 100 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J1459 | Privigen | 500 mg | 300= 150,000 mg/day | 300= 150,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J1460 | Gamastan | 1 cc | 10= 10 cc/day | 10= 10 cc/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| J1551 | Cutaquig | 100 mg | 1,600= 160,000 mg/day | 1,600= 160,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1552 | Alyglo | 500 mg | 1,200= 600,000 mg/day | 1,200= 600,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1554 | Asceniv | 500 mg | 240= 120,000 mg/day | 240= 120,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1555 | Cuvitru | 100 mg | 480= 48,000 mg/day | 480= 48,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1556 | Bivigam | 500 mg | 240= 120,000 mg/day | 240= 120,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1557 | Gammaplex | 500 mg | 300= 150,000 mg/day | 300= 150,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J1558 | Xembify | 100 mg | 480= 48,000 mg/day | 480= 48,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1559 | Hizentra | 100 mg | 2,400= 240,000 mg/day | 2,400= 240,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J1560 | Gamastan | 10 cc | 1= 10 cc/day | 1= 10 cc/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| J1561 | Gammaked | 500 mg | 360= 180,000 mg/day | 360= 180,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J1566 | Gammagard S-D | 500 mg | 300= 150,000 mg/day | 300= 150,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J1568 | Octagam | 500 mg | 300= 150,000 mg/day | 300= 150,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J1569 | Gammagard Liquid | 500 mg | 400= 200,000 mg/day | 400= 200,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J1570 | Ganciclovir | 500 mg | 4= 2,000 mg/day | 4= 2,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1571 | Hepagam B | 0.5 ml | 20= 10 ml/day | 20= 10 ml/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1572 | Flebogamma 10% Dif | 500 mg | 180= 90,000 mg/day | 180= 90,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1573 | Hepagam B | 0.5 ml | 130= 65 ml/day | 130= 65 ml/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1575 | Hyqvia | 100 mg | 3,000= 300,000 mg/day | 3,000= 300,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1576 | Panzyga | 500 mg | 600= 300,000 mg/day | 600= 300,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1580 | Gentamicin Sulfate | 80 mg | 9= 720 mg/day | 9= 720 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1595 | Copaxone | 20 mg | 1= 20 mg/day | 2= 40 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| J1596 | Glycopyrrolate Injection | 0.1 mg | 18= 1.8 mg/day | 18= 1.8 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J1597 | Glyrx-Pf | 0.1 mg | 8= 0.8 mg/day | 8= 0.8 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1598 | Glycopyrrolate | 0.1 mg | 12= 1.2 mg/day | 12= 1.2 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J1599 | Panzyga | 500 mg | 300= 150,000 mg/day | 300= 150,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J1600 | Gold Sodium Thiomalate | 50 mg | 2= 100 mg/day | 0 — not payable | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: CMS Policy. | ||||||
| J1602 | Simponi Aria | 1 mg | 300= 300 mg/day | 300= 300 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1610 | Glucagen | 1 mg | 2= 2 mg/day | 3= 3 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. | ||||||
| J1611 | Glucagon Emergency | 1 mg | 2= 2 mg/day | 2= 2 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1626 | Granisetron Hcl | 100 mcg | 30= 3,000 mcg/day | 30= 3,000 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J1627 | Sustol | 0.1 mg | 100= 10 mg/day | 100= 10 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1628 | Tremfya | 1 mg | 200= 200 mg/day | 200= 200 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1630 | Haloperidol Lactate | 5 mg | 5= 25 mg/day | 7= 35 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J1631 | Haldol Decanoate 100 | 50 mg | 9= 450 mg/day | 9= 450 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1632 | Zulresso | 1 mg | 700= 700 mg/day | 700= 700 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J1640 | Panhematin | 1 mg | 672= 672 mg/day | 672= 672 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1642 | Heparin | 10 units | 100= 1,000 units/day | 150= 1,500 units/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J1643 | Heparin Sodium | 1000 units | 40= 40,000 units/day | 40= 40,000 units/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1644 | Heparin (Porcine) In NaCl | 1000 units | 40= 40,000 units/day | 50= 50,000 units/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J1645 | Fragmin | 2500 iu | 10= 25,000 iu/day | 10= 25,000 iu/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1650 | Enoxaparin Sodium | 10 mg | 30= 300 mg/day | 30= 300 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1652 | Arixtra | 0.5 mg | 20= 10 mg/day | 20= 10 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1670 | Hypertet S-D | 250 units | 1= 250 units/day | 2= 500 units/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J1675 | Histrelin Acetate | 10 micrograms | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Drug discontinued | ||||||
| J1700 | Hydrocortisone Acetate | 25 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Drug discontinued | ||||||
| J1720 | Solu-Cortef | up to 100 mg | 10 | 10 | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J1726 | Makena | 10 mg | 28= 280 mg/day | 28= 280 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1729 | Hydroxyprogesterone Caproate | 10 mg | 25= 250 mg/day | 25= 250 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J1730 | Diazoxide | 300 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Drug discontinued | ||||||
| J1738 | Anjeso | 1 mg | 30= 30 mg/day | 30= 30 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1740 | Boniva | 1 mg | 3= 3 mg/day | 3= 3 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1741 | Caldolor | 100 mg | 8= 800 mg/day | 32= 3,200 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| J1742 | Corvert | 1 mg | 2= 2 mg/day | 4= 4 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. | ||||||
| J1743 | Elaprase | 1 mg | 66= 66 mg/day | 66= 66 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J1744 | Firazyr | 1 mg | 30= 30 mg/day | 90= 90 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1745 | Remicade | 10 mg | 150= 1,500 mg/day | 150= 1,500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1746 | Trogarzo | 10 mg | 200= 2,000 mg/day | 200= 2,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1747 | Spevigo | 1 mg | 900= 900 mg/day | 900= 900 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1748 | Zymfentra | 10 mg | 12= 120 mg/day | 12= 120 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1749 | Aurlumyn | 0.1 mcg | 2,000= 200 mcg/day | 2,000= 200 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J1750 | Infed | 50 mg | 45= 2,250 mg/day | 45= 2,250 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J1756 | Venofer | 1 mg | 500= 500 mg/day | 500= 500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J1786 | Cerezyme | 10 units | 680= 6,800 units/day | 680= 6,800 units/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J1790 | Droperidol | up to 5 mg | 2 | 2 | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1800 | Propranolol Hcl | 1 mg | 6= 6 mg/day | 12= 12 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J1808 | Folic Acid | 0.1 mg | 150= 15 mg/day | 150= 15 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1815 | Apidra | 5 units | 8= 40 units/day | 200= 1,000 units/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Society Comment. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. | ||||||
| J1817 | Humalog | 50 units | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J1823 | Uplizna | 1 mg | 300= 300 mg/day | 300= 300 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1826 | Avonex | 30 mcg | 1= 30 mcg/day | 1= 30 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1830 | Betaseron | 0.25 mg | 1= 0.25 mg/day | 1= 0.25 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1833 | Cresemba | 1 mg | 372= 372 mg/day | 1,116= 1,116 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1835 | Itraconazole | 50 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Drug discontinued | ||||||
| J1836 | Metronidazole | 10 mg | 400= 4,000 mg/day | 400= 4,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1885 | Ketorolac Tromethamine | 15 mg | 8= 120 mg/day | 8= 120 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1930 | Somatuline Depot | 1 mg | 120= 120 mg/day | 120= 120 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1931 | Aldurazyme | 0.1 mg | 609= 60.9 mg/day | 609= 60.9 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: CMS Workgroup | ||||||
| J1932 | Lanreotide | 1 mg | 120= 120 mg/day | 120= 120 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1938 | Furosemide | 1 mg | 5,360= 5,360 mg/day | 5,360= 5,360 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1939 | Bumetanide | 0.5 mg | 24= 12 mg/day | 24= 12 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1943 | Aristada Initio | 1 mg | 675= 675 mg/day | 675= 675 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1944 | Aristada | 1 mg | 1,064= 1,064 mg/day | 1,064= 1,064 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1950 | Lupron Depot | 3.75 mg | 12= 45 mg/day | 12= 45 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J1951 | Fensolvi | 0.25 mg | 180= 45 mg/day | 180= 45 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1952 | Camcevi | 1 mg | 42= 42 mg/day | 42= 42 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1953 | Keppra | 10 mg | 300= 3,000 mg/day | 300= 3,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1954 | Lutrate Depot | 7.5 mg | 3= 22.5 mg/day | 3= 22.5 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1955 | Carnitor | 1 gm | 11= 11 gm/day | 11= 11 gm/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J1956 | Levofloxacin | 250 mg | 4= 1,000 mg/day | 4= 1,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J1960 | Levorphanol Tartrate | 2 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Drug discontinued | ||||||
| J1980 | Levsin | 0.25 mg | 2= 0.5 mg/day | 8= 2 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J1990 | Chlordiazepoxide Hcl | 100 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Drug discontinued | ||||||
| J2002 | Lidocaine In D5W | 1 mg | 2,000= 2,000 mg/day | 4,000= 4,000 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| J2003 | Lidocaine Hcl | 1 mg | 300= 300 mg/day | 300= 300 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: CMS Workgroup | ||||||
| J2004 | Xylocaine-Mpf/Epinephrine | 1 mg | 500= 500 mg/day | 500= 500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: CMS Workgroup | ||||||
| J2010 | Lincocin | up to 300 mg | 10 | 10 | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J2020 | Linezolid | 200 mg | 6= 1,200 mg/day | 6= 1,200 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2021 | Linezolid | 200 mg | 6= 1,200 mg/day | 6= 1,200 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2060 | Ativan | 2 mg | 4= 8 mg/day | 10= 20 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J2062 | Adasuve | 1 mg | 10= 10 mg/day | 10= 10 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2170 | Increlex | 1 mg | 8= 8 mg/day | 8= 8 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2175 | Demerol | 100 mg | 4= 400 mg/day | 6= 600 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: CMS Workgroup | ||||||
| J2180 | Mepergan | 50 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Drug discontinued | ||||||
| J2182 | Nucala | 1 mg | 300= 300 mg/day | 300= 300 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2183 | Meropenem | 100 mg | 60= 6,000 mg/day | 60= 6,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2184 | Meropenem | 100 mg | 60= 6,000 mg/day | 60= 6,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2185 | Meropenem | 100 mg | 60= 6,000 mg/day | 60= 6,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2186 | Vabomere | (10 mg/10mg) 20 mg | 600 | 600 | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2210 | Methylergonovine Maleate | 0.2 mg | 1= 0.2 mg/day | 5= 1 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J2212 | Relistor | 0.1 mg | 240= 24 mg/day | 240= 24 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2246 | Micafungin Sodium | 1 mg | 150= 150 mg/day | 150= 150 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2247 | Micafungin | 1 mg | 150= 150 mg/day | 150= 150 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2248 | Micafungin Sodium | 1 mg | 150= 150 mg/day | 300= 300 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. | ||||||
| J2250 | Midazolam Hcl | 1 mg | 22= 22 mg/day | 30= 30 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J2251 | Midazolam HCl | 1 mg | 22= 22 mg/day | 22= 22 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2252 | Midazolam-Sodium Chloride (Pf) | 1 mg | 400= 400 mg/day | 400= 400 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J2253 | Seizalam | 1 mg | 10= 10 mg/day | 10= 10 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2260 | Milrinone In 5% Dextrose | 5 mg | 4= 20 mg/day | 16= 80 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J2265 | Minocin | 1 mg | 400= 400 mg/day | 400= 400 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2267 | Omvoh | 1 mg | 900= 900 mg/day | 900= 900 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2270 | Morphine Sulfate | 10 mg | 9= 90 mg/day | 15= 150 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J2272 | Morphine Sulfate | 10 mg | 9= 90 mg/day | 15= 150 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J2274 | Duramorph | 10 mg | 250= 2,500 mg/day | 100= 1,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J2277 | Aphexda | 0.25 mg | 750= 187.5 mg/day | 750= 187.5 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2278 | Prialt | 1 mcg | 1,000= 1,000 mcg/day | 1,000= 1,000 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J2280 | Avelox I.V. | 100 mg | 4= 400 mg/day | 8= 800 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. | ||||||
| J2281 | Moxifloxacin Hcl | 100 mg | 4= 400 mg/day | 4= 400 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2290 | Nafcillin sodium | 20 mg | 300= 6,000 mg/day | 300= 6,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2300 | Nalbuphine Hcl | 10 mg | 4= 40 mg/day | 10= 100 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: CMS Workgroup | ||||||
| J2312 | Naloxone Hcl | 0.01 mg | 1,000= 10 mg/day | 1,000= 10 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2313 | Zimhi | 0.01 mg | 1,000= 10 mg/day | 1,000= 10 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2315 | Vivitrol | 1 mg | 380= 380 mg/day | 380= 380 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2320 | Nandrolone Decanoate | 50 mg | 4= 200 mg/day | 4= 200 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2323 | Tysabri | 1 mg | 300= 300 mg/day | 300= 300 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2325 | Nesiritide | 0.1 mg | 0 — not payable | 34= 3.4 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: CMS Workgroup. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. | ||||||
| J2326 | Spinraza | 0.1 mg | 120= 12 mg/day | 120= 12 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2327 | Skyrizi | 1 mg | 1,200= 1,200 mg/day | 1,200= 1,200 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2350 | Ocrevus | 1 mg | 600= 600 mg/day | 600= 600 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2351 | Ocrevus Zunovo | 1 mg | 920= 920 mg/day | 920= 920 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2353 | Sandostatin Lar Depot | 1 mg | 60= 60 mg/day | 60= 60 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Society Comment | ||||||
| J2354 | Octreotide Acetate | 25 mcg | 60= 1,500 mcg/day | 60= 1,500 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2355 | Oprelvekin | 5 mg | 2= 10 mg/day | 2= 10 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2356 | Tezspire | 1 mg | 210= 210 mg/day | 210= 210 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2357 | Xolair | 5 mg | 120= 600 mg/day | 120= 600 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2358 | Zyprexa Relprevv | 1 mg | 405= 405 mg/day | 405= 405 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2359 | Olanzapine | 0.5 mg | 60= 30 mg/day | 60= 30 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2360 | Orphenadrine Citrate | 60 mg | 2= 120 mg/day | 3= 180 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2401 | Chloroprocaine Hcl | 1 mg | 1,000= 1,000 mg/day | 1,000= 1,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2402 | Clorotekal | 1 mg | 50= 50 mg/day | 50= 50 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2403 | Iheezo | 1 mg | 1,600= 1,600 mg/day | 1,600= 1,600 mg/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Anatomic Consideration | ||||||
| J2404 | Cardene I.V. | 0.1 mg | 3,600= 360 mg/day | 3,600= 360 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2405 | Ondansetron Hcl | 1 mg | 64= 64 mg/day | 64= 64 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2406 | Kimyrsa | 10 mg | 120= 1,200 mg/day | 120= 1,200 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2407 | Orbactiv | 10 mg | 120= 1,200 mg/day | 120= 1,200 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2410 | Oxymorphone Hcl | 1 mg | 2= 2 mg/day | 2= 2 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J2425 | Kepivance | 50 mcg | 125= 6,250 mcg/day | 125= 6,250 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J2426 | Invega Sustenna | 1 mg | 1,560= 1,560 mg/day | 1,560= 1,560 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2427 | Invega Trinza | 1mg | 1,560= 1,560 mg/day | 1,560= 1,560 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2428 | Erzofri | 1 mg | 351= 351 mg/day | 351= 351 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2430 | Pamidronate Disodium | 30 mg | 3= 90 mg/day | 3= 90 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2440 | Papaverine Hcl | up to 60 mg | 4 | 4 | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J2460 | Oxytetracycline Hcl | 50 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Drug discontinued | ||||||
| J2468 | Posfrea | 25 mcg | 10= 250 mcg/day | 10= 250 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2469 | Palonosetron | 25 mcg | 60= 1,500 mcg/day | 60= 1,500 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2470 | Pantoprazole Sodium | 40 mg | 6= 240 mg/day | 6= 240 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2471 | Pantoprazole Sodium | 40 mg | 6= 240 mg/day | 6= 240 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2472 | Pantoprazole sodium - NaCl (Baxter) | 40 mg | 6= 240 mg/day | 6= 240 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2501 | Paricalcitol | 1 mcg | 2= 2 mcg/day | 25= 25 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J2502 | Signifor Lar | 1 mg | 60= 60 mg/day | 60= 60 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2506 | Neulasta | 0.5 mg | 12= 6 mg/day | 12= 6 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2507 | Krystexxa | 1 mg | 8= 8 mg/day | 8= 8 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2508 | Elfabrio | 1 mg | 160= 160 mg/day | 160= 160 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J2510 | Penicillin G Procaine | up to 600000 units | 4 | 4 | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2515 | Nembutal Sodium | 50 mg | 1= 50 mg/day | 8= 400 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J2540 | Penicillin G Potassium | 600000 units | 75= 45,000,000 units/day | 75= 45,000,000 units/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2543 | Piperacillin And Tazobactam | 1.125 gm | 16= 18 gm/day | 20= 22.5 gm/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2545 | Nebupent | 300 mg | 1= 300 mg/day | 1= 300 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2547 | Rapivab | 1 mg | 600= 600 mg/day | 600= 600 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2550 | Phenergan | 50 mg | 3= 150 mg/day | 3= 150 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2560 | Phenobarbital Sodium | 120 mg | 1= 120 mg/day | 16= 1,920 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J2562 | Mozobil | 1 mg | 48= 48 mg/day | 48= 48 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J2590 | Oxytocin | 10 units | 3= 30 units/day | 15= 150 units/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2597 | Ddavp | 1 mcg | 45= 45 mcg/day | 45= 45 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2601 | Vasopressin | 1 unit | 160= 160 unit/day | 160= 160 unit/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J2650 | Prednisolone Acetate | up to 1 ml | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Drug discontinued | ||||||
| J2670 | Tolazoline Hcl | 25 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Drug discontinued | ||||||
| J2675 | Progesterone | 50 mg | 1= 50 mg/day | 1= 50 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2679 | Fluphenazine Hcl | 1.25 mg | 8= 10 mg/day | 8= 10 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2680 | Fluphenazine Decanoate | 25 mg | 4= 100 mg/day | 4= 100 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2690 | Procainamide Hcl | 1 gm | 4= 4 gm/day | 4= 4 gm/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| J2700 | Oxacillin | 250 mg | 48= 12,000 mg/day | 48= 12,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J2704 | Diprivan | 10 mg | 80= 800 mg/day | 400= 4,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J2710 | Neostigmine Methylsulfate | 0.5 mg | 2= 1 mg/day | 10= 5 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Society Comment. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. | ||||||
| J2720 | Protamine Sulfate | 10 mg | 5= 50 mg/day | 10= 100 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. | ||||||
| J2724 | Ceprotin | 10 units | 3,500= 35,000 units/day | 3,500= 35,000 units/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J2725 | Protirelin | 250 mcg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Drug discontinued | ||||||
| J2730 | Protopam Chloride | 1 gm | 2= 2 gm/day | 2= 2 gm/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2760 | Phentolamine Mesylate | 5 mg | 2= 10 mg/day | 2= 10 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2765 | Metoclopramide Hcl | 10 mg | 10= 100 mg/day | 18= 180 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Society Comment. | ||||||
| J2770 | Synercid | 500 mg | 6= 3,000 mg/day | 7= 3,500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2777 | Vabysmo | 0.1 mg | 120= 12 mg/day | 120= 12 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2778 | Lucentis | 0.1 mg | 10= 1 mg/day | 10= 1 mg/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Anatomic Consideration | ||||||
| J2779 | Susvimo | 0.1 mg | 200= 20 mg/day | 200= 20 mg/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Anatomic Consideration | ||||||
| J2781 | Syfovre | 1 mg | 30= 30 mg/day | 30= 30 mg/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Anatomic Consideration | ||||||
| J2782 | Izervay | 0.1 mg | 40= 4 mg/day | 40= 4 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J2783 | Elitek | 0.5 mg | 60= 30 mg/day | 60= 30 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2785 | Lexiscan | 0.1 mg | 4= 0.4 mg/day | 4= 0.4 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2786 | Cinqair | 1 mg | 500= 500 mg/day | 500= 500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J2787 | Photrexa Cross-Linking | 3 ml | 2= 6 ml/day | 2= 6 ml/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2788 | Hyperrho S-D | 50 mcg | 1= 50 mcg/day | 1= 50 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2790 | Hyperrho S-D | 300 mcg (1500 iu) | 1= 300 mcg (1500 iu)/day | 3= 900 mcg (1500 iu)/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J2791 | Rhophylac | 100 iu | 15= 1,500 iu/day | 15= 1,500 iu/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J2792 | Winrho Sdf | 100 iu | 450= 45,000 iu/day | 450= 45,000 iu/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2793 | Arcalyst | 1 mg | 320= 320 mg/day | 320= 320 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2794 | Risperdal Consta | 0.5 mg | 100= 50 mg/day | 100= 50 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2795 | Naropin | 1 mg | 200= 200 mg/day | 2,400= 2,400 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. | ||||||
| J2797 | Rolapitant | 0.5 mg | 333= 166.5 mg/day | 333= 166.5 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2798 | Perseris | 0.5 mg | 240= 120 mg/day | 240= 120 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2799 | Uzedy | 1 mg | 250= 250 mg/day | 250= 250 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2800 | Methocarbamol | 10 ml | 3= 30 ml/day | 3= 30 ml/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2801 | Rykindo | 0.5 mg | 100= 50 mg/day | 100= 50 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2802 | Nplate | 1 mcg | 1,500= 1,500 mcg/day | 1,500= 1,500 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2804 | Rifampin | 1 mg | 1,200= 1,200 mg/day | 1,200= 1,200 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2805 | Kinevac | 5 mcg | 3= 15 mcg/day | 3= 15 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2810 | Theophylline In 5% Dextrose | 40 mg | 5= 200 mg/day | 20= 800 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J2820 | Leukine | 50 mcg | 15= 750 mcg/day | 10= 500 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J2840 | Kanuma | 1 mg | 160= 160 mg/day | 160= 160 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2850 | Chirhostim | 1 mcg | 16= 16 mcg/day | 48= 48 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J2860 | Sylvant | 10 mg | 170= 1,700 mg/day | 170= 1,700 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2865 | Sulfamethoxazole-Trimethoprim | 5mg-1mg | 3,000= 15,000 mg-1mg/day | 3,000= 15,000 mg-1mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2916 | Ferrlecit | 12.5 mg | 20= 250 mg/day | 20= 250 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J2919 | Methylprednisolone Sodium Succinate | 5 mg | 5,400= 27,000 mg/day | 5,400= 27,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2941 | Serostim | 1 mg | 8= 8 mg/day | 8= 8 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2950 | Promazine Hcl | 25 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Drug discontinued | ||||||
| J2993 | Retavase | 18.1 mg | 2= 36.2 mg/day | 2= 36.2 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2997 | Activase | 1 mg | 100= 100 mg/day | 100= 100 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J2998 | Ryplazim | 1 mg | 1,032= 1,032 mg/day | 1,032= 1,032 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J3000 | Streptomycin Sulfate | 1 gm | 2= 2 gm/day | 2= 2 gm/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J3010 | Fentanyl Citrate | 0.1 mg | 100= 10 mg/day | 100= 10 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: CMS Workgroup | ||||||
| J3030 | Sumatriptan Succinate | 6 mg | 1= 6 mg/day | 2= 12 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| J3031 | Ajovy Syringe | 1 mg | 675= 675 mg/day | 675= 675 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J3032 | Vyepti | 1 mg | 300= 300 mg/day | 300= 300 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J3055 | Talvey | 0.25 mg | 480= 120 mg/day | 480= 120 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J3060 | Elelyso | 10 units | 760= 7,600 units/day | 760= 7,600 units/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J3070 | Pentazocine | 30 mg | 3= 90 mg/day | 3= 90 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J3090 | Sivextro | 1 mg | 200= 200 mg/day | 200= 200 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J3095 | Vibativ | 10 mg | 150= 1,500 mg/day | 150= 1,500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J3101 | Tnkase | 1 mg | 50= 50 mg/day | 50= 50 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J3105 | Terbutaline Sulfate | 1 mg | 2= 2 mg/day | 4= 4 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J3110 | Forteo | 10 mcg | 2= 20 mcg/day | 2= 20 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J3111 | Evenity | 1 mg | 210= 210 mg/day | 210= 210 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J3121 | Testosterone Enanthate | 1 mg | 400= 400 mg/day | 400= 400 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J3145 | Aveed | 1 mg | 750= 750 mg/day | 750= 750 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J3230 | Chlorpromazine Hcl | 50 mg | 2= 100 mg/day | 6= 300 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J3240 | Thyrogen | 0.9 mg | 1= 0.9 mg/day | 1= 0.9 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J3241 | Tepezza | 10 mg | 500= 5,000 mg/day | 500= 5,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J3243 | Tigecycline | 1 mg | 150= 150 mg/day | 200= 200 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J3244 | Tigecycline | 1 mg | 150= 150 mg/day | 200= 200 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J3245 | Ilumya | 1 mg | 100= 100 mg/day | 100= 100 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J3246 | Aggrastat | 0.25 mg | 1= 0.25 mg/day | 100= 25 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J3247 | Cosentyx | 1 mg | 1,000= 1,000 mg/day | 1,000= 1,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J3250 | Tigan | 200 mg | 2= 400 mg/day | 4= 800 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J3260 | Tobramycin Sulfate | 80 mg | 8= 640 mg/day | 12= 960 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J3262 | Actemra | 1 mg | 800= 800 mg/day | 800= 800 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J3263 | Loqtorzi | 1 mg | 480= 480 mg/day | 480= 480 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J3265 | Torsemide | 10 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Drug discontinued | ||||||
| J3285 | Remodulin | 1 mg | 1= 1 mg/day | 9= 9 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: CMS Workgroup. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| J3299 | Xipere | 1 mg | 72= 72 mg/day | 72= 72 mg/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Anatomic Consideration | ||||||
| J3300 | Triesence | 1 mg | 80= 80 mg/day | 80= 80 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J3301 | Kenalog-10 | 10 mg | 16= 160 mg/day | 16= 160 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J3302 | Triamcinolone Diacetate | 5 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Drug discontinued | ||||||
| J3303 | Hexatrione 2% | 5 mg | 24= 120 mg/day | 24= 120 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J3304 | Zilretta | 1 mg | 64= 64 mg/day | 64= 64 mg/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Anatomic Consideration | ||||||
| J3315 | Trelstar | 3.75 mg | 6= 22.5 mg/day | 6= 22.5 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J3316 | Triptodur | 3.75 mg | 6= 22.5 mg/day | 6= 22.5 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J3350 | Urea | 40 gm | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Drug discontinued | ||||||
| J3357 | Stelara | 1 mg | 90= 90 mg/day | 90= 90 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J3358 | Stelara | 1 mg | 520= 520 mg/day | 520= 520 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J3360 | Diazepam | 5 mg | 6= 30 mg/day | 6= 30 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J3373 | Vancomycin Hcl | 10 mg | 600= 6,000 mg/day | 600= 6,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J3374 | Vancomycin Hcl | 10 mg | 600= 6,000 mg/day | 600= 6,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J3375 | Vancomycin Hcl | 10 mg | 600= 6,000 mg/day | 600= 6,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J3380 | Entyvio | 1 mg | 300= 300 mg/day | 300= 300 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J3385 | Vpriv | 100 units | 80= 8,000 units/day | 80= 8,000 units/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J3391 | Lenmeldy | per treatment dose | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| J3392 | Casgevy | per treatment | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| J3396 | Visudyne | 0.1 mg | 150= 15 mg/day | 150= 15 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J3397 | Mepsevii | 1 mg | 600= 600 mg/day | 600= 600 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J3398 | Luxturna | 1 billion vector genomes | 150= 150 billion vector genomes/day | 150= 150 billion vector genomes/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale CMS Policy | ||||||
| J3399 | Zolgensma | per tx dose (up to 5 x10^15 vg?) | 1 | 1 | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J3401 | Vyjuvek | 0.1 ml | 25= 2.5 ml/day | 25= 2.5 ml/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J3410 | Hydroxyzine Hcl | 25 mg | 8= 200 mg/day | 16= 400 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J3411 | Thiamine Hcl | 100 mg | 4= 400 mg/day | 8= 800 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J3415 | Pyridoxine Hcl | 100 mg | 6= 600 mg/day | 6= 600 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J3420 | Cyanocobalamin | 1000 mcg | 1= 1,000 mcg/day | 1= 1,000 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J3424 | Cyanokit | 25 mg | 400= 10,000 mg/day | 400= 10,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J3425 | Hydroxocobalamin | 10 mcg | 20= 200 mcg/day | 20= 200 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J3430 | Phytonadione | 1 mg | 25= 25 mg/day | 50= 50 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J3465 | Vfend Iv | 10 mg | 40= 400 mg/day | 120= 1,200 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J3470 | Amphadase | 150 units | 3= 450 units/day | 3= 450 units/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J3471 | Vitrase | 1 usp unit | 999= 999 usp unit/day | 999= 999 usp unit/day | Line edit (MAI 1) | |
| Edit type Line Edit (MAI 1): Per-line limit: units are checked per claim line; medically necessary units beyond the limit may be billable on separate lines with appropriate modifiers. CMS rationale Code Descriptor / CPT Instruction | ||||||
| J3472 | Hyaluronidase | 1000 usp units | 2= 2,000 usp units/day | 2= 2,000 usp units/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J3473 | Hylenex | 1 usp unit | 450= 450 usp unit/day | 450= 450 usp unit/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J3475 | Magnesium Sulfate | 500 mg | 20= 10,000 mg/day | 80= 40,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J3480 | Dextrose 5%-Potassium Chloride | 2 meq | 40= 80 meq/day | 200= 400 meq/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J3485 | Retrovir | 10 mg | 160= 1,600 mg/day | 160= 1,600 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J3486 | Geodon | 10 mg | 4= 40 mg/day | 4= 40 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J3489 | Reclast | 1 mg | 5= 5 mg/day | 5= 5 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J7030 | Sodium Chloride | 1000 cc | 5= 5,000 cc/day | 20= 20,000 cc/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J7040 | Sodium Chloride | 500 ml | 6= 3,000 ml/day | 12= 6,000 ml/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J7042 | Dextrose 5%-0.9% Nacl | 500 ml | 6= 3,000 ml/day | 12= 6,000 ml/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J7050 | Sodium Chloride | 250 cc | 10= 2,500 cc/day | 20= 5,000 cc/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J7060 | Dextrose | 500 ml | 10= 5,000 ml/day | 10= 5,000 ml/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J7070 | Dextrose | 1000 cc | 4= 4,000 cc/day | 7= 7,000 cc/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J7100 | Lmd In Dextrose | 500 ml | 2= 1,000 ml/day | 2= 1,000 ml/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J7120 | Lactated Ringers | up to 1000 cc | 4 | 20 | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J7121 | Dextrose In Lactated Ringers | 1000 cc | 4= 4,000 cc/day | 5= 5,000 cc/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: CMS Workgroup. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. | ||||||
| J7131 | Sodium Chloride | 1 ml | 500= 500 ml/day | 500= 500 ml/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J7165 | Balfaxar | per factor ix iu | 5,000 | 5,000 | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J7168 | Kcentra | 1 iu | 5,000= 5,000 iu/day | 5,000= 5,000 iu/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J7169 | Andexxa | 10 mg | 180= 1,800 mg/day | 180= 1,800 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J7170 | Hemlibra | 0.5 mg | 1,800= 900 mg/day | 1,800= 900 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J7172 | Hympavzi | 0.5 mg | 600= 300 mg/day | 600= 300 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J7175 | Coagadex | 1 iu | 9,000= 9,000 iu/day | 9,000= 9,000 iu/day | Line edit (MAI 1) | |
| Edit type Line Edit (MAI 1): Per-line limit: units are checked per claim line; medically necessary units beyond the limit may be billable on separate lines with appropriate modifiers. CMS rationale Prescribing Information | ||||||
| J7177 | Fibryga | 1 mg | 10,500= 10,500 mg/day | 10,500= 10,500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J7178 | Riastap | 1 mg | 7,700= 7,700 mg/day | 7,700= 7,700 mg/day | Line edit (MAI 1) | |
| Edit type Line Edit (MAI 1): Per-line limit: units are checked per claim line; medically necessary units beyond the limit may be billable on separate lines with appropriate modifiers. CMS rationale Prescribing Information | ||||||
| J7179 | Vonvendi | 1 iu | 7,500= 7,500 iu/day | 9,600= 9,600 iu/day | Line edit (MAI 1) | |
| Edit type Line Edit (MAI 1): Per-line limit: units are checked per claim line; medically necessary units beyond the limit may be billable on separate lines with appropriate modifiers. CMS rationale Clinical: CMS Workgroup | ||||||
| J7180 | Corifact | 1 iu | 6,000= 6,000 iu/day | 6,000= 6,000 iu/day | Line edit (MAI 1) | |
| Edit type Line Edit (MAI 1): Per-line limit: units are checked per claim line; medically necessary units beyond the limit may be billable on separate lines with appropriate modifiers. CMS rationale Prescribing Information | ||||||
| J7181 | Tretten | 1 iu | 3,850= 3,850 iu/day | 3,850= 3,850 iu/day | Line edit (MAI 1) | |
| Edit type Line Edit (MAI 1): Per-line limit: units are checked per claim line; medically necessary units beyond the limit may be billable on separate lines with appropriate modifiers. CMS rationale Clinical: CMS Workgroup | ||||||
| J7182 | Novoeight | 1 iu | 22,000= 22,000 iu/day | 22,000= 22,000 iu/day | Line edit (MAI 1) | |
| Edit type Line Edit (MAI 1): Per-line limit: units are checked per claim line; medically necessary units beyond the limit may be billable on separate lines with appropriate modifiers. CMS rationale Clinical: Data | ||||||
| J7183 | Wilate | 1 i.u. vwf:rco | 7,500= 7,500 i.u. vwf:rco/day | 9,600= 9,600 i.u. vwf:rco/day | Line edit (MAI 1) | |
| Edit type Line Edit (MAI 1): Per-line limit: units are checked per claim line; medically necessary units beyond the limit may be billable on separate lines with appropriate modifiers. CMS rationale Clinical: CMS Workgroup | ||||||
| J7185 | Xyntha | 1 iu | 22,000= 22,000 iu/day | 22,000= 22,000 iu/day | Line edit (MAI 1) | |
| Edit type Line Edit (MAI 1): Per-line limit: units are checked per claim line; medically necessary units beyond the limit may be billable on separate lines with appropriate modifiers. CMS rationale Clinical: Data | ||||||
| J7186 | Alphanate | per factor viii iu | 7,500 | 9,600 | Line edit (MAI 1) | |
| Edit type Line Edit (MAI 1): Per-line limit: units are checked per claim line; medically necessary units beyond the limit may be billable on separate lines with appropriate modifiers. CMS rationale Clinical: CMS Workgroup | ||||||
| J7187 | Humate-P | 1 iu | 7,500= 7,500 iu/day | 9,600= 9,600 iu/day | Line edit (MAI 1) | |
| Edit type Line Edit (MAI 1): Per-line limit: units are checked per claim line; medically necessary units beyond the limit may be billable on separate lines with appropriate modifiers. CMS rationale Clinical: Data | ||||||
| J7188 | Obizur | 1 iu | 22,000= 22,000 iu/day | 22,000= 22,000 iu/day | Line edit (MAI 1) | |
| Edit type Line Edit (MAI 1): Per-line limit: units are checked per claim line; medically necessary units beyond the limit may be billable on separate lines with appropriate modifiers. CMS rationale Clinical: CMS Workgroup | ||||||
| J7189 | Novoseven Rt | 1 mcg | 13,000= 13,000 mcg/day | 26,000= 26,000 mcg/day | Line edit (MAI 1) | |
| Office edit Line Edit (MAI 1): Per-line limit: units are checked per claim line; medically necessary units beyond the limit may be billable on separate lines with appropriate modifiers. CMS rationale: Clinical: Data. Hospital edit Line Edit (MAI 1): Per-line limit: units are checked per claim line; medically necessary units beyond the limit may be billable on separate lines with appropriate modifiers. CMS rationale: Prescribing Information. | ||||||
| J7190 | Alphanate | 1 iu | 22,000= 22,000 iu/day | 22,000= 22,000 iu/day | Line edit (MAI 1) | |
| Edit type Line Edit (MAI 1): Per-line limit: units are checked per claim line; medically necessary units beyond the limit may be billable on separate lines with appropriate modifiers. CMS rationale Clinical: Data | ||||||
| J7192 | Advate | 1 iu | 22,000= 22,000 iu/day | 22,000= 22,000 iu/day | Line edit (MAI 1) | |
| Edit type Line Edit (MAI 1): Per-line limit: units are checked per claim line; medically necessary units beyond the limit may be billable on separate lines with appropriate modifiers. CMS rationale Clinical: Data | ||||||
| J7193 | Alphanine Sd | 1 iu | 4,000= 4,000 iu/day | 20,000= 20,000 iu/day | Line edit (MAI 1) | |
| Edit type Line Edit (MAI 1): Per-line limit: units are checked per claim line; medically necessary units beyond the limit may be billable on separate lines with appropriate modifiers. CMS rationale Clinical: Data | ||||||
| J7194 | Profilnine | 1 iu | 9,000= 9,000 iu/day | 9,000= 9,000 iu/day | Line edit (MAI 1) | |
| Edit type Line Edit (MAI 1): Per-line limit: units are checked per claim line; medically necessary units beyond the limit may be billable on separate lines with appropriate modifiers. CMS rationale Clinical: CMS Workgroup | ||||||
| J7195 | Benefix | 1 iu | 6,000= 6,000 iu/day | 20,000= 20,000 iu/day | Line edit (MAI 1) | |
| Edit type Line Edit (MAI 1): Per-line limit: units are checked per claim line; medically necessary units beyond the limit may be billable on separate lines with appropriate modifiers. CMS rationale Clinical: CMS Workgroup | ||||||
| J7196 | Antithrombin Recombinant | 50 i.u. | 175= 8,750 i.u./day | 175= 8,750 i.u./day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J7197 | Thrombate Iii | 1 iu | 6,300= 6,300 iu/day | 6,300= 6,300 iu/day | Line edit (MAI 1) | |
| Edit type Line Edit (MAI 1): Per-line limit: units are checked per claim line; medically necessary units beyond the limit may be billable on separate lines with appropriate modifiers. CMS rationale Prescribing Information | ||||||
| J7198 | Feiba Nf | 1 iu | 6,000= 6,000 iu/day | 30,000= 30,000 iu/day | Line edit (MAI 1) | |
| Office edit Line Edit (MAI 1): Per-line limit: units are checked per claim line; medically necessary units beyond the limit may be billable on separate lines with appropriate modifiers. CMS rationale: Clinical: Data. Hospital edit Line Edit (MAI 1): Per-line limit: units are checked per claim line; medically necessary units beyond the limit may be billable on separate lines with appropriate modifiers. CMS rationale: Prescribing Information. | ||||||
| J7200 | Rixubis | 1 iu | 20,000= 20,000 iu/day | 20,000= 20,000 iu/day | Line edit (MAI 1) | |
| Edit type Line Edit (MAI 1): Per-line limit: units are checked per claim line; medically necessary units beyond the limit may be billable on separate lines with appropriate modifiers. CMS rationale Clinical: CMS Workgroup | ||||||
| J7201 | Alprolix | 1 iu | 9,000= 9,000 iu/day | 9,000= 9,000 iu/day | Line edit (MAI 1) | |
| Edit type Line Edit (MAI 1): Per-line limit: units are checked per claim line; medically necessary units beyond the limit may be billable on separate lines with appropriate modifiers. CMS rationale Clinical: CMS Workgroup | ||||||
| J7202 | Idelvion | 1 iu | 11,550= 11,550 iu/day | 11,550= 11,550 iu/day | Line edit (MAI 1) | |
| Edit type Line Edit (MAI 1): Per-line limit: units are checked per claim line; medically necessary units beyond the limit may be billable on separate lines with appropriate modifiers. CMS rationale Clinical: CMS Workgroup | ||||||
| J7203 | Rebinyn | 1 iu | 12,000= 12,000 iu/day | 12,000= 12,000 iu/day | Line edit (MAI 1) | |
| Edit type Line Edit (MAI 1): Per-line limit: units are checked per claim line; medically necessary units beyond the limit may be billable on separate lines with appropriate modifiers. CMS rationale Clinical: CMS Workgroup | ||||||
| J7204 | Esperoct | 1 iu | 19,500= 19,500 iu/day | 19,500= 19,500 iu/day | Line edit (MAI 1) | |
| Edit type Line Edit (MAI 1): Per-line limit: units are checked per claim line; medically necessary units beyond the limit may be billable on separate lines with appropriate modifiers. CMS rationale Prescribing Information | ||||||
| J7205 | Eloctate | 1 iu | 9,750= 9,750 iu/day | 9,750= 9,750 iu/day | Line edit (MAI 1) | |
| Edit type Line Edit (MAI 1): Per-line limit: units are checked per claim line; medically necessary units beyond the limit may be billable on separate lines with appropriate modifiers. CMS rationale Clinical: Data | ||||||
| J7207 | Adynovate | 1 iu | 22,500= 22,500 iu/day | 22,500= 22,500 iu/day | Line edit (MAI 1) | |
| Edit type Line Edit (MAI 1): Per-line limit: units are checked per claim line; medically necessary units beyond the limit may be billable on separate lines with appropriate modifiers. CMS rationale Prescribing Information | ||||||
| J7208 | Jivi | 1 iu | 12,000= 12,000 iu/day | 18,000= 18,000 iu/day | Line edit (MAI 1) | |
| Edit type Line Edit (MAI 1): Per-line limit: units are checked per claim line; medically necessary units beyond the limit may be billable on separate lines with appropriate modifiers. CMS rationale Prescribing Information | ||||||
| J7209 | Nuwiq | 1 iu | 7,500= 7,500 iu/day | 7,500= 7,500 iu/day | Line edit (MAI 1) | |
| Edit type Line Edit (MAI 1): Per-line limit: units are checked per claim line; medically necessary units beyond the limit may be billable on separate lines with appropriate modifiers. CMS rationale Clinical: Data | ||||||
| J7210 | Afstyla | 1 iu | 22,000= 22,000 iu/day | 22,000= 22,000 iu/day | Line edit (MAI 1) | |
| Edit type Line Edit (MAI 1): Per-line limit: units are checked per claim line; medically necessary units beyond the limit may be billable on separate lines with appropriate modifiers. CMS rationale Clinical: CMS Workgroup | ||||||
| J7211 | Kovaltry | 1 iu | 22,000= 22,000 iu/day | 22,000= 22,000 iu/day | Line edit (MAI 1) | |
| Edit type Line Edit (MAI 1): Per-line limit: units are checked per claim line; medically necessary units beyond the limit may be billable on separate lines with appropriate modifiers. CMS rationale Clinical: CMS Workgroup | ||||||
| J7212 | Sevenfact | 1 mcg | 90,000= 90,000 mcg/day | 90,000= 90,000 mcg/day | Line edit (MAI 1) | |
| Edit type Line Edit (MAI 1): Per-line limit: units are checked per claim line; medically necessary units beyond the limit may be billable on separate lines with appropriate modifiers. CMS rationale Prescribing Information | ||||||
| J7213 | Ixinity | 1 iu | 12,000= 12,000 iu/day | 12,000= 12,000 iu/day | Line edit (MAI 1) | |
| Edit type Line Edit (MAI 1): Per-line limit: units are checked per claim line; medically necessary units beyond the limit may be billable on separate lines with appropriate modifiers. CMS rationale Prescribing Information | ||||||
| J7214 | Altuviiio | 1 iu | 7,500= 7,500 iu/day | 9,600= 9,600 iu/day | Line edit (MAI 1) | |
| Edit type Line Edit (MAI 1): Per-line limit: units are checked per claim line; medically necessary units beyond the limit may be billable on separate lines with appropriate modifiers. CMS rationale Clinical: CMS Workgroup | ||||||
| J7294 | Annovera | each | 1 | 1 | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J7295 | Nuvaring | each | 1 | 1 | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J7296 | Kyleena | 19.5 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J7297 | Liletta | 52 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J7298 | Mirena | 52 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J7300 | Paragard | per dose | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J7301 | Skyla | 13.5 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J7304 | Xulane | each | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J7307 | Nexplanon | singular implant | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J7308 | Levulan | 354 mg | 3= 1,062 mg/day | 3= 1,062 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J7311 | Retisert | 0.01 mg | 118= 1.18 mg/day | 118= 1.18 mg/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Anatomic Consideration | ||||||
| J7312 | Ozurdex | 0.1 mg | 14= 1.4 mg/day | 14= 1.4 mg/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Anatomic Consideration | ||||||
| J7313 | Iluvien | 0.01 mg | 38= 0.38 mg/day | 38= 0.38 mg/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Anatomic Consideration | ||||||
| J7314 | Yutiq | 0.01 mg | 36= 0.36 mg/day | 36= 0.36 mg/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Anatomic Consideration | ||||||
| J7315 | Mitosol | 0.2 mg | 2= 0.4 mg/day | 2= 0.4 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J7316 | Ocriplasmin | 0.125 mg | 3= 0.38 mg/day | 3= 0.38 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J7318 | Durolane | 1 mg | 120= 120 mg/day | 120= 120 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J7320 | Genvisc 850 | 1 mg | 50= 50 mg/day | 50= 50 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J7321 | Hyalgan | per dose | 2 | 2 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Anatomic Consideration | ||||||
| J7322 | Hymovis | 1 mg | 64= 64 mg/day | 64= 64 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J7323 | Euflexxa | per dose | 2 | 2 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Anatomic Consideration | ||||||
| J7324 | Orthosvisc | per dose | 2 | 2 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Anatomic Consideration | ||||||
| J7325 | Synvisc | 1 mg | 96= 96 mg/day | 96= 96 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J7326 | Gel-One | per dose | 2 | 2 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Anatomic Consideration | ||||||
| J7327 | Monovisc | per dose | 2 | 2 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Anatomic Consideration | ||||||
| J7328 | Gelsyn-3 | 0.1 mg | 336= 33.6 mg/day | 336= 33.6 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J7329 | Trivisc | 1 mg | 50= 50 mg/day | 50= 50 mg/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Anatomic Consideration | ||||||
| J7330 | Maci | 1 implant | 1= 1 implant/day | 1= 1 implant/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Nature of Service/Procedure | ||||||
| J7331 | SynoJoynt | 1 mg | 40= 40 mg/day | 40= 40 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J7332 | Triluron | 1 mg | 40= 40 mg/day | 40= 40 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J7336 | Qutenza | 1 sq cm | 1,120= 1,120 sq cm/day | 1,120= 1,120 sq cm/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J7340 | Duopa | 5 mg/20 mg 100 ml | 1= 5 mg/20 mg 100 ml/day | 1= 5 mg/20 mg 100 ml/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J7342 | Otiprio | 6 mg | 10= 60 mg/day | 10= 60 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J7345 | Ameluz | 10 mg | 600= 6,000 mg/day | 600= 6,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J7351 | Durysta | 1 mcg | 20= 20 mcg/day | 20= 20 mcg/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Anatomic Consideration | ||||||
| J7352 | Scenesse | 1 mg | 16= 16 mg/day | 16= 16 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J7353 | Nexobrid | 1 gm (of 8.8% gel) | 300= 300 gm (of 8.8% gel)/day | 300= 300 gm (of 8.8% gel)/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J7354 | Ycanth | per 3.2 mg single-use applicator | 2 | 2 | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J7355 | Idose Tr | 1 mcg | 150= 150 mcg/day | 150= 150 mcg/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Anatomic Consideration | ||||||
| J7356 | Vyalev | 0.25 mg - 5 mg | 960= 240 mg - 5 mg/day | 960= 240 mg - 5 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J7402 | Sinuva | 10 mcg | 270= 2,700 mcg/day | 270= 2,700 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J7500 | Azasan | 50 mg | 0 — not payable | 15= 750 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Oral Medication; Not Payable. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| J7501 | Azathioprine Sodium | 100 mg | 1= 100 mg/day | 8= 800 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: CMS Workgroup. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| J7502 | Cyclosporine Modified | 100 mg | 0 — not payable | 60= 6,000 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Oral Medication; Not Payable. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. | ||||||
| J7503 | Envarsus Xr | 0.25 mg | 0 — not payable | 120= 30 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Oral Medication; Not Payable. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| J7504 | Atgam | 250 mg | 15= 3,750 mg/day | 15= 3,750 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J7507 | Prograf | 1 mg | 0 — not payable | 40= 40 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Oral Medication; Not Payable. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| J7508 | Astagraf Xl | 0.1 mg | 0 — not payable | 300= 30 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: CMS Policy. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| J7509 | Medrol | 4 mg | 0 — not payable | 60= 240 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Oral Medication; Not Payable. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| J7510 | Prednisolone | 5 mg | 0 — not payable | 60= 300 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Oral Medication; Not Payable. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| J7511 | Thymoglobulin | 25 mg | 9= 225 mg/day | 9= 225 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J7512 | Prednisone | 1 mg | 0 — not payable | 300= 300 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Oral Medication; Not Payable. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| J7514 | Myhibbin | 100 mg | 30= 3,000 mg/day | 30= 3,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J7515 | Cyclosporine | 25 mg | 0 — not payable | 90= 2,250 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Oral Medication; Not Payable. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. | ||||||
| J7516 | Sandimmune | 250 mg | 1= 250 mg/day | 4= 1,000 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| J7517 | Cellcept | 250 mg | 0 — not payable | 16= 4,000 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Oral Medication; Not Payable. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. | ||||||
| J7518 | Mycophenolic Acid | 180 mg | 0 — not payable | 12= 2,160 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: CMS Policy. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Society Comment. | ||||||
| J7519 | Cellcept - Iv | 10 mg | 500= 5,000 mg/day | 500= 5,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J7520 | Rapamune | 1 mg | 0 — not payable | 40= 40 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Oral Medication; Not Payable. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| J7521 | Prograf Granules | 0.1 mg | 300= 30 mg/day | 300= 30 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J7525 | Prograf | 5 mg | 2= 10 mg/day | 2= 10 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J7527 | Afinitor | 0.25 mg | 40= 10 mg/day | 40= 10 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J7601 | Ohtuvayre | 3 mg | 2= 6 mg/day | No published MUE | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| J7605 | Brovana | 15 mcg | 2= 30 mcg/day | 0 — not payable | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: CMS Policy. | ||||||
| J7606 | Perforomist | 20 mcg | 2= 40 mcg/day | 0 — not payable | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: CMS Policy. | ||||||
| J7607 | Levalbuterol | 0.5 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Compounded Drug Policy | ||||||
| J7608 | Acetylcysteine | 1 gm | 3= 3 gm/day | 0 — not payable | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: CMS Policy. | ||||||
| J7609 | Albuterol | 1 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Compounded Drug Policy | ||||||
| J7610 | Albuterol | 1 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Compounded Drug Policy | ||||||
| J7611 | Albuterol Sulfate | 1 mg | 10= 10 mg/day | 0 — not payable | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: CMS Policy. | ||||||
| J7612 | Levalbuterol Concentrate | 0.5 mg | 10= 5 mg/day | 0 — not payable | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: CMS Policy. | ||||||
| J7613 | Albuterol Sulfate | 1 mg | 10= 10 mg/day | 0 — not payable | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: CMS Policy. | ||||||
| J7614 | Levalbuterol | 0.5 mg | 10= 5 mg/day | 0 — not payable | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: CMS Policy. | ||||||
| J7615 | Levalbuterol | 0.5 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Compounded Drug Policy | ||||||
| J7620 | Albuterol ipratropium | 2.5 mg/0.5 mg | 6= 15 mg/0.5 mg/day | 0 — not payable | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: CMS Policy. | ||||||
| J7622 | Beclomethasone | 1 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Compounded Drug Policy | ||||||
| J7624 | Betamethasone | 1 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Compounded Drug Policy | ||||||
| J7626 | Budesonide | up to 0.50 mg | 2 | 0 — not payable | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: CMS Policy. | ||||||
| J7627 | Budesonide | 0.5 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Compounded Drug Policy | ||||||
| J7628 | Bitolterol Mesylate | 1 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Compounded Drug Policy | ||||||
| J7629 | Bitolterol Mesylate | 1 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Compounded Drug Policy | ||||||
| J7631 | Cromolyn Sodium | 10 mg | 4= 40 mg/day | 0 — not payable | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: CMS Policy. | ||||||
| J7632 | Cromolyn Sodium | 10 milligrams | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Compounded Drug Policy | ||||||
| J7633 | Budesonide | 0.25 milligram | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Drug discontinued | ||||||
| J7634 | Budesonide | 0.25 milligram | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Compounded Drug Policy | ||||||
| J7635 | Atropine | 1 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Compounded Drug Policy | ||||||
| J7636 | Atropine | 1 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Compounded Drug Policy | ||||||
| J7637 | Dexamethasone | j7620 1 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Compounded Drug Policy | ||||||
| J7638 | Dexamethasone | j7620, 1 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Compounded Drug Policy | ||||||
| J7639 | Pulmozyme | 1 mg | 3= 3 mg/day | 0 — not payable | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: CMS Policy. | ||||||
| J7640 | Formoterol | 12 micrograms | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Compounded Drug Policy | ||||||
| J7641 | Flunisolide | 1 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Compounded Drug Policy | ||||||
| J7642 | Glycopyrrolate | 1 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Compounded Drug Policy | ||||||
| J7643 | Glycopyrrolate | 1 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Compounded Drug Policy | ||||||
| J7644 | Ipratropium Bromide | 1 mg | 3= 3 mg/day | 0 — not payable | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: CMS Policy. | ||||||
| J7645 | Ipratropium Bromide | 1 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Compounded Drug Policy | ||||||
| J7647 | Isoetharine Hcl | 1 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Compounded Drug Policy | ||||||
| J7648 | Isoetharine Hcl | 1 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Drug discontinued | ||||||
| J7649 | Isoetharine Hcl | 1 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Drug discontinued | ||||||
| J7650 | Isoetharine Hcl | 1 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Compounded Drug Policy | ||||||
| J7657 | Isoproterenol Hcl | 1 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Compounded Drug Policy | ||||||
| J7658 | Isoproterenol Hcl | 1 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Drug discontinued | ||||||
| J7659 | Isoproterenol Hcl | 1 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Drug discontinued | ||||||
| J7660 | Isoproterenol Hcl | 1 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Compounded Drug Policy | ||||||
| J7665 | Aridol | 5 mg | 127= 635 mg/day | 127= 635 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J7667 | Metaproterenol Sulfate | 10 milligrams | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Compounded Drug Policy | ||||||
| J7668 | Metaproterenol Sulfate | 10 milligrams | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Drug discontinued | ||||||
| J7669 | Metaproterenol Sulfate | 10 milligrams | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Drug discontinued | ||||||
| J7670 | Metaproterenol Sulfate | 10 milligrams | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Compounded Drug Policy | ||||||
| J7674 | Provocholine | 1 mg | 100= 100 mg/day | 100= 100 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J7676 | Pentamidine Isethionate | 300 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Compounded Drug Policy | ||||||
| J7677 | Yupelri | 1 mcg | 175= 175 mcg/day | 175= 175 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J7680 | Terbutaline Sulfate | 1 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Compounded Drug Policy | ||||||
| J7681 | Terbutaline Sulfate | 1 milligram | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Compounded Drug Policy | ||||||
| J7682 | Bethkis | 300 mg | 2= 600 mg/day | 0 — not payable | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: CMS Policy. | ||||||
| J7683 | Triamcinolone | 1 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Compounded Drug Policy | ||||||
| J7684 | Triamcinolone | 1 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Compounded Drug Policy | ||||||
| J7685 | Tobramycin | 300 milligrams | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Compounded Drug Policy | ||||||
| J7686 | Tyvaso | 1.74 mg | 1= 1.74 mg/day | 0 — not payable | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: CMS Policy. | ||||||
| J8501 | Aprepitant | 5 mg | 0 — not payable | 57= 285 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Oral Medication; Not Payable. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: CMS Policy. | ||||||
| J8510 | Myleran | 2 mg | 0 — not payable | 5= 10 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Oral Medication; Not Payable. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| J8515 | Cabergoline | 0.25 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J8530 | Cyclophosphamide | 25 mg | 0 — not payable | 60= 1,500 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Oral Medication; Not Payable. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. | ||||||
| J8540 | Dexamethasone | 0.25 mg | 0 — not payable | 80= 20 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Oral Medication; Not Payable. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. | ||||||
| J8560 | Etoposide | 50 mg | 0 — not payable | 6= 300 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Oral Medication; Not Payable. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| J8565 | Iressa | 250 mg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J8600 | Alkeran | 2 mg | 0 — not payable | 40= 80 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Oral Medication; Not Payable. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| J8610 | Methotrexate | 2.5 mg | 0 — not payable | 20= 50 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Oral Medication; Not Payable. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| J8655 | Akynzeo | 300 mg/0.5 mg | 1= 300 mg/0.5 mg/day | 1= 300 mg/0.5 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J8670 | Varubi | 1 mg | 0 — not payable | 180= 180 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Oral Medication; Not Payable. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| J8700 | Temodar | 5 mg | 0 — not payable | 120= 600 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Oral Medication; Not Payable. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| J8705 | Hycamtin | 0.25 mg | 0 — not payable | 22= 5.5 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Oral Medication; Not Payable. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| J9000 | Adriamycin | 10 mg | 20= 200 mg/day | 20= 200 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J9011 | Datroway | 1 mg | 600= 600 mg/day | 600= 600 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J9015 | Proleukin | per single use vial | 1 | 1 | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J9017 | Arsenic Trioxide | 1 mg | 30= 30 mg/day | 30= 30 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J9021 | Rylaze | 0.1 mg | 1,500= 150 mg/day | 1,500= 150 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9022 | Tecentriq | 10 mg | 168= 1,680 mg/day | 168= 1,680 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9023 | Bavencio | 10 mg | 140= 1,400 mg/day | 140= 1,400 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J9024 | Tecentriq Hybreza | 5 mg | 375= 1,875 mg/day | 375= 1,875 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9025 | Azacitidine | 1 mg | 300= 300 mg/day | 300= 300 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9026 | Imdelltra | 1 mg | 10= 10 mg/day | 10= 10 mg/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale CMS Policy | ||||||
| J9027 | Clofarabine | 1 mg | 100= 100 mg/day | 100= 100 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J9028 | Anktiva | 1 mcg | 400= 400 mcg/day | 400= 400 mcg/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale CMS Policy | ||||||
| J9029 | Adstiladrin | per therapeutic dose | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Prescribing Information | ||||||
| J9030 | Bcg (Tice Strain) | 1 mg | 50= 50 mg/day | 50= 50 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9032 | Beleodaq | 10 mg | 300= 3,000 mg/day | 300= 3,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9033 | Treanda | 1 mg | 300= 300 mg/day | 300= 300 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9034 | Bendeka | 1 mg | 360= 360 mg/day | 360= 360 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9035 | Avastin | 10 mg | 230= 2,300 mg/day | 230= 2,300 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J9036 | Belrapzo | 1 mg | 360= 360 mg/day | 360= 360 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9038 | Niktimvo | 0.1 mg | 360= 36 mg/day | 360= 36 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J9039 | Blincyto | 1 mcg | 210= 210 mcg/day | 210= 210 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9040 | Bleomycin Sulfate | 15 units | 4= 60 units/day | 4= 60 units/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9041 | Bortezomib | 0.1 mg | 35= 3.5 mg/day | 35= 3.5 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J9042 | Adcetris | 1 mg | 200= 200 mg/day | 200= 200 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J9043 | Jevtana | 1 mg | 60= 60 mg/day | 60= 60 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9045 | Carboplatin | 50 mg | 22= 1,100 mg/day | 22= 1,100 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9046 | Bortezomib | 0.1 mg | 35= 3.5 mg/day | 35= 3.5 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9047 | Kyprolis | 1 mg | 210= 210 mg/day | 210= 210 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9048 | Bortezomib | 0.1 mg | 35= 3.5 mg/day | 35= 3.5 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9049 | Bortezomib | 0.1 mg | 35= 3.5 mg/day | 35= 3.5 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9050 | Bicnu | 100 mg | 6= 600 mg/day | 6= 600 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9051 | Bortezomib (Maia) | 0.1 mg | 35= 3.5 mg/day | 35= 3.5 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9052 | Carmustine | 100 mg | 6= 600 mg/day | 6= 600 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9054 | Boruzu | 0.1 mg | 70= 7 mg/day | 70= 7 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J9055 | Erbitux | 10 mg | 150= 1,500 mg/day | 150= 1,500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9056 | Vivimusta | 1 mg | 360= 360 mg/day | 360= 360 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9057 | Aliqopa | 1 mg | 60= 60 mg/day | 60= 60 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9060 | Cisplatin | 10 mg | 24= 240 mg/day | 24= 240 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9061 | Rybrevant | 2 mg | 1,050= 2,100 mg/day | 1,050= 2,100 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9063 | Elahere | 1 mg | 900= 900 mg/day | 900= 900 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9065 | Cladribine | 1 mg | 100= 100 mg/day | 100= 100 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9071 | Cyclophosphamide | 5 mg | 1,500= 7,500 mg/day | 1,500= 7,500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9072 | Cyclophosphamide (Avyxa) | 5 mg | 1,500= 7,500 mg/day | 1,500= 7,500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9073 | Cyclophosphamide (Ingenus) | 5 mg | 1,500= 7,500 mg/day | 1,500= 7,500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9074 | Cyclophosphamide (Sandoz) | 5 mg | 1,500= 7,500 mg/day | 1,500= 7,500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9075 | Cyclophosphamide | 5 mg | 1,500= 7,500 mg/day | 1,500= 7,500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9076 | Cyclophosphamide (Baxter) | 5 mg | 1,500= 7,500 mg/day | 1,500= 7,500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9100 | Cytarabine | 100 mg | 120= 12,000 mg/day | 120= 12,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Society Comment | ||||||
| J9118 | Asparlas | 10 units | 750= 7,500 units/day | 750= 7,500 units/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J9119 | Libtayo | 1 mg | 700= 700 mg/day | 700= 700 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9120 | Cosmegen | 0.5 mg | 5= 2.5 mg/day | 5= 2.5 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J9130 | Dacarbazine | 100 mg | 24= 2,400 mg/day | 24= 2,400 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Society Comment | ||||||
| J9144 | Darzalex Faspro | 10 mg | 180= 1,800 mg/day | 180= 1,800 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9145 | Darzalex | 10 mg | 240= 2,400 mg/day | 240= 2,400 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9150 | Daunorubicin Hcl | 10 mg | 12= 120 mg/day | 12= 120 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J9153 | Vyxeos | 1 mg/2.27 mg | 132= 132 mg/2.27 mg/day | 132= 132 mg/2.27 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9155 | Firmagon | 1 mg | 240= 240 mg/day | 240= 240 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9161 | Lymphir | 1 mcg | 1,500= 1,500 mcg/day | 1,500= 1,500 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J9171 | Docetaxel | 1 mg | 300= 300 mg/day | 300= 300 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9172 | Docivyx | 1 mg | 300= 300 mg/day | 300= 300 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9173 | Imfinzi | 10 mg | 150= 1,500 mg/day | 150= 1,500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9174 | Beizray | 1 mg | 320= 320 mg/day | 320= 320 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J9175 | Elliotts B | 1 ml | 10= 10 ml/day | 10= 10 ml/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J9176 | Empliciti | 1 mg | 3,000= 3,000 mg/day | 3,000= 3,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9177 | Padcev | 0.25 mg | 520= 130 mg/day | 520= 130 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J9178 | Ellence | 2 mg | 150= 300 mg/day | 150= 300 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J9179 | Halaven | 0.1 mg | 50= 5 mg/day | 50= 5 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J9181 | Etopophos | 10 mg | 100= 1,000 mg/day | 100= 1,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Society Comment | ||||||
| J9185 | Fludarabine Phosphate | 50 mg | 2= 100 mg/day | 2= 100 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9190 | Fluorouracil | 500 mg | 20= 10,000 mg/day | 20= 10,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J9196 | Gemcitabine | 200 mg | 19= 3,800 mg/day | 19= 3,800 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J9198 | Infugem | 100 mg | 38= 3,800 mg/day | 38= 3,800 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J9200 | Floxuridine | 500 mg | 5= 2,500 mg/day | 20= 10,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J9201 | Gemcitabine | 200 mg | 20= 4,000 mg/day | 20= 4,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9202 | Zoladex | 3.6 mg | 3= 10.8 mg/day | 3= 10.8 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9203 | Mylotarg | 0.1 mg | 180= 18 mg/day | 180= 18 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9204 | Poteligeo | 1 mg | 160= 160 mg/day | 160= 160 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9205 | Onivyde | 1 mg | 215= 215 mg/day | 215= 215 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J9206 | Camptosar | 20 mg | 42= 840 mg/day | 42= 840 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9207 | Ixempra | 1 mg | 90= 90 mg/day | 90= 90 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J9208 | Ifex | 1 gm | 15= 15 gm/day | 15= 15 gm/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J9209 | Mesna | 200 mg | 55= 11,000 mg/day | 55= 11,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J9210 | Gamifant | 1 mg | 1,500= 1,500 mg/day | 1,500= 1,500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9211 | Idamycin Pfs | 5 mg | 6= 30 mg/day | 6= 30 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9213 | Interferon | 3 million units | 12= 36 million units/day | 12= 36 million units/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9214 | Intron A | 1 mil units | 100= 100 mil units/day | 100= 100 mil units/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J9215 | Alferon N | 250,000 iu | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Drug discontinued | ||||||
| J9216 | Actimmune | 3 million units | 2= 6 million units/day | 0 — not payable | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: CMS Policy. | ||||||
| J9217 | Eligard | 7.5 mg | 6= 45 mg/day | 6= 45 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9218 | Leuprolide Acetate | 1 mg | 1= 1 mg/day | 1= 1 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9219 | Leuprolide Acetate | 65 mg | 1= 65 mg/day | 0 — not payable | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: CMS Policy. | ||||||
| J9220 | Bludigo | 1 mg | 40= 40 mg/day | 40= 40 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9223 | Zepzelca | 0.1 mg | 120= 12 mg/day | 120= 12 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J9225 | Histrelin | 50 mg | 1= 50 mg/day | 1= 50 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9226 | Supprelin La | 50 mg | 1= 50 mg/day | 1= 50 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9227 | Sarclisa | 10 mg | 150= 1,500 mg/day | 150= 1,500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9228 | Yervoy | 1 mg | 1,100= 1,100 mg/day | 1,100= 1,100 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9229 | Besponsa | 0.1 mg | 27= 2.7 mg/day | 27= 2.7 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J9230 | Mechlorethamine Hydrochloride | 10 mg | 5= 50 mg/day | 5= 50 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9245 | Alkeran | 50 mg | 9= 450 mg/day | 11= 550 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Society Comment | ||||||
| J9246 | Evomela | 1 mg | 300= 300 mg/day | 300= 300 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9248 | Hepzato | 1 mg | 250= 250 mg/day | 250= 250 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9249 | Melphalan (Apotex) | 1 mg | 48= 48 mg/day | 48= 48 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9260 | Methotrexate | 50 mg | 400= 20,000 mg/day | 400= 20,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9261 | Arranon | 50 mg | 80= 4,000 mg/day | 80= 4,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9262 | Synribo | 0.01 mg | 700= 7 mg/day | 700= 7 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9263 | Oxaliplatin | 0.5 mg | 700= 350 mg/day | 700= 350 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J9264 | Abraxane | 1 mg | 800= 800 mg/day | 800= 800 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9266 | Oncaspar | 1 each | 2 | 2 | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9267 | Paclitaxel | 1 mg | 750= 750 mg/day | 750= 750 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9268 | Nipent | 10 mg | 1= 10 mg/day | 1= 10 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9269 | Elzonris | 10 mcg | 200= 2,000 mcg/day | 200= 2,000 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J9271 | Keytruda | 1 mg | 400= 400 mg/day | 400= 400 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9272 | Jemperli | 10 mg | 100= 1,000 mg/day | 100= 1,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9273 | Tivdak | 1 mg | 200= 200 mg/day | 200= 200 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9274 | Kimmtrak | 1 mcg | 100= 100 mcg/day | 100= 100 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J9275 | Unloxcyt | 2 mg | 600= 1,200 mg/day | 600= 1,200 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9276 | Ziihera | 2 mg | 1,500= 3,000 mg/day | 1,500= 3,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9280 | Mitomycin | 5 mg | 12= 60 mg/day | 12= 60 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9281 | Jelmyto | 1 mg | 80= 80 mg/day | 80= 80 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J9285 | Lartruvo | 10 mg | 200= 2,000 mg/day | 200= 2,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J9286 | Columvi | 2.5 mg | 12= 30 mg/day | 12= 30 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9289 | Opdivo Qvantig | 2 mg | 600= 1,200 mg/day | 600= 1,200 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9292 | Axtle | 10 mg | 150= 1,500 mg/day | 150= 1,500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9293 | Mitoxantrone Hcl | 5 mg | 8= 40 mg/day | 8= 40 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J9294 | Pemetrexed | 10 mg | 150= 1,500 mg/day | 150= 1,500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9295 | Portrazza | 1 mg | 800= 800 mg/day | 800= 800 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9296 | Pemetrexed | 10 mg | 150= 1,500 mg/day | 150= 1,500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9297 | Pemetrexed | 10 mg | 150= 1,500 mg/day | 150= 1,500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9298 | Opdualag | 3 mg - 1 mg | 160= 480 mg - 1 mg/day | 160= 480 mg - 1 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9299 | Opdivo | 1 mg | 480= 480 mg/day | 480= 480 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9301 | Gazyva | 10 mg | 100= 1,000 mg/day | 100= 1,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9302 | Arzerra | 10 mg | 200= 2,000 mg/day | 200= 2,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9303 | Vectibix | 10 mg | 90= 900 mg/day | 90= 900 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9304 | Pemfexy | 10 mg | 150= 1,500 mg/day | 150= 1,500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9305 | Alimta | 10 mg | 150= 1,500 mg/day | 150= 1,500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9306 | Perjeta | 1 mg | 840= 840 mg/day | 840= 840 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9307 | Folotyn | 1 mg | 80= 80 mg/day | 80= 80 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9308 | Cyramza | 5 mg | 280= 1,400 mg/day | 280= 1,400 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J9309 | Polivy | 1 mg | 280= 280 mg/day | 280= 280 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J9311 | Rituxan Hycela | 10 mg (rituximab) | 160= 1,600 mg (rituximab)/day | 160= 1,600 mg (rituximab)/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9312 | Rituxan | 10 mg | 150= 1,500 mg/day | 150= 1,500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9313 | Lumoxiti | 0.01 mg | 600= 6 mg/day | 600= 6 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9314 | Pemetrexed | 10 mg | 150= 1,500 mg/day | 150= 1,500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9316 | Phesgo | 10 mg | 180= 1,800 mg/day | 180= 1,800 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9317 | Trodelvy | 2.5 mg | 648= 1,620 mg/day | 648= 1,620 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J9318 | Romidepsin | 0.1 mg | 475= 47.5 mg/day | 475= 47.5 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J9319 | Istodax | 0.1 mg | 500= 50 mg/day | 500= 50 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J9320 | Zanosar | 1 gm | 4= 4 gm/day | 4= 4 gm/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9321 | Epkinly | 0.16 mg | 300= 48 mg/day | 300= 48 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9322 | Pemetrexed Disodium | 10 mg | 150= 1,500 mg/day | 150= 1,500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9323 | Pemetrexed (Hospira) | 10 mg | 150= 1,500 mg/day | 150= 1,500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9324 | Pemrydi Rtu | 10 mg | 150= 1,500 mg/day | 150= 1,500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9325 | Imlygic | 1 million pfu | 400= 400 million pfu/day | 400= 400 million pfu/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9328 | Temodar | 1 mg | 400= 400 mg/day | 400= 400 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J9329 | Tevimbra | 1 mg | 200= 200 mg/day | 200= 200 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9330 | Temsirolimus | 1 mg | 50= 50 mg/day | 50= 50 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9331 | Fyarro | 1 mg | 300= 300 mg/day | 300= 300 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9332 | Vyvgart | 2 mg | 600= 1,200 mg/day | 600= 1,200 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9333 | Rystiggo | 1 mg | 840= 840 mg/day | 840= 840 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9334 | Vyvgart Hytrulo | 2 mg | 504= 1,008 mg/day | 504= 1,008 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9341 | Tepylute | 1 mg | 60= 60 mg/day | 60= 60 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9342 | Thiotepa | 1 mg | 60= 60 mg/day | 450= 450 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9345 | Zynyz | 1 mg | 500= 500 mg/day | 500= 500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9347 | Imjudo | 1 mg | 300= 300 mg/day | 300= 300 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9348 | Danyelza | 1 mg | 160= 160 mg/day | 160= 160 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J9349 | Monjuvi | 2 mg | 900= 1,800 mg/day | 900= 1,800 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9350 | Lunsumio | 1 mg | 60= 60 mg/day | 60= 60 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9351 | Hycamtin | 0.1 mg | 120= 12 mg/day | 120= 12 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Society Comment | ||||||
| J9352 | Yondelis | 0.1 mg | 40= 4 mg/day | 40= 4 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9353 | Margenza | 5 mg | 450= 2,250 mg/day | 450= 2,250 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9354 | Kadcyla | 1 mg | 600= 600 mg/day | 600= 600 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9355 | Herceptin | 10 mg | 120= 1,200 mg/day | 120= 1,200 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9356 | Herceptin Hylecta | 10 mg | 60= 600 mg/day | 60= 600 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9357 | Valrubicin | 200 mg | 4= 800 mg/day | 4= 800 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9358 | Enhertu | 1 mg | 1,000= 1,000 mg/day | 1,000= 1,000 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J9359 | Zynlonta | 0.075 mg | 400= 30 mg/day | 400= 30 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J9360 | Vinblastine Sulfate | 1 mg | 40= 40 mg/day | 40= 40 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9361 | Ryzneuta | 0.5 mg | 40= 20 mg/day | 40= 20 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9370 | Vincristine Sulfate | 1 mg | 4= 4 mg/day | 4= 4 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J9376 | Veopoz | 1 mg | 4,800= 4,800 mg/day | 4,800= 4,800 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9380 | Tecvayli | 0.5 mg | 612= 306 mg/day | 612= 306 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9381 | Tzield | 5 mcg | 800= 4,000 mcg/day | 800= 4,000 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| J9382 | Bizengri | 1 mg | 750= 750 mg/day | 750= 750 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9390 | Navelbine | 10 mg | 36= 360 mg/day | 36= 360 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9393 | Fulvestrant | 25 mg | 20= 500 mg/day | 20= 500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9394 | Fulvestrant | 25 mg | 20= 500 mg/day | 20= 500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9395 | Faslodex | 25 mg | 20= 500 mg/day | 20= 500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| J9400 | Zaltrap | 1 mg | 500= 500 mg/day | 500= 500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| J9600 | Photofrin | 75 mg | 4= 300 mg/day | 4= 300 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| P9041 | Albumin (Human) | 50 ml | 5= 250 ml/day | 100= 5,000 ml/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| P9045 | Albuked 5 | 250 ml | 20= 5,000 ml/day | 20= 5,000 ml/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| P9046 | Albuked 25 | 20 ml | 25= 500 ml/day | 40= 800 ml/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| P9047 | Albuked 25 | 50 ml | 20= 1,000 ml/day | 20= 1,000 ml/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| Q0138 | Feraheme | 1 mg | 510= 510 mg/day | 510= 510 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q0139 | Feraheme | 1 mg | 510= 510 mg/day | 510= 510 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q0162 | Ondansetron | 1 mg | 0 — not payable | 24= 24 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Oral Medication; Not Payable. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| Q0164 | Prochlorperazine Maleate | 5 mg | 0 — not payable | 8= 40 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Oral Medication; Not Payable. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| Q0166 | Granisetron HCl | 1 mg | 0 — not payable | 2= 2 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Oral Medication; Not Payable. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| Q0167 | Dronabinol | 2.5 mg | 0 — not payable | 108= 270 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Oral Medication; Not Payable. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| Q0169 | Promethazine Hcl | 12.5 mg | 0 — not payable | 12= 150 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Oral Medication; Not Payable. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| Q0180 | Anzemet | 100 mg | 0 — not payable | 1= 100 mg/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Oral Medication; Not Payable. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. | ||||||
| Q0224 | Pemgarda | 4500 mg | 1= 4,500 mg/day | 1= 4,500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q0249 | Actemra | 1 mg | 1,600= 1,600 mg/day | 1,600= 1,600 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q2009 | Cerebyx | 50 mg pe/ml | 100= 5,000 mg pe/ml/day | 100= 5,000 mg pe/ml/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: CMS Workgroup. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. | ||||||
| Q2038 | Influenza Virus Vaccine | per therapeutic dose | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| Q2043 | Provenge | per infusion (minimum 50 million cells) | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| Q2049 | — | — | 10 | 10 | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| Q2050 | Doxil | 10 mg | 14= 140 mg/day | 20= 200 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: CMS Workgroup | ||||||
| Q2057 | Tecelra | per therapeutic dose | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| Q2058 | Aucatzyl | per therapeutic dose | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| Q3027 | Avonex | 1 mcg | 30= 30 mcg/day | 30= 30 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q3028 | Rebif | 1 mcg | 0 — not payable | 0 — not payable | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| Q4074 | Ventavis | up to 20 mcg | 3 | 0 — not payable | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: CMS Policy. | ||||||
| Q4081 | Epogen | 100 units | 100= 10,000 units/day | 400= 40,000 units/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| Q5098 | Imuldosa | 1 mg | 520= 520 mg/day | 520= 520 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q5099 | Steqeyma | 1 mg | 520= 520 mg/day | 520= 520 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q5100 | Yesintek | 1 mg | 520= 520 mg/day | 520= 520 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q5101 | Zarxio | 1 mcg | 1,500= 1,500 mcg/day | 1,500= 1,500 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: CMS Workgroup | ||||||
| Q5103 | Inflectra | 10 mg | 150= 1,500 mg/day | 150= 1,500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q5104 | Renflexis | 10 mg | 150= 1,500 mg/day | 150= 1,500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q5105 | Retacrit | 100 units | 100= 10,000 units/day | 400= 40,000 units/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| Q5106 | Retacrit | 1000 units | 60= 60,000 units/day | 60= 60,000 units/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q5107 | Mvasi | 10 mg | 230= 2,300 mg/day | 230= 2,300 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| Q5108 | Fulphila | 0.5 mg | 12= 6 mg/day | 12= 6 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q5110 | Nivestym | 1 mcg | 1,500= 1,500 mcg/day | 1,500= 1,500 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q5111 | Udenyca | 0.5 mg | 12= 6 mg/day | 12= 6 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q5112 | Ontruzant | 10 mg | 120= 1,200 mg/day | 120= 1,200 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q5113 | Herzuma | 10 mg | 120= 1,200 mg/day | 120= 1,200 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Society Comment | ||||||
| Q5114 | Ogivri | 10 mg | 120= 1,200 mg/day | 120= 1,200 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q5115 | Truxima | 10 mg | 150= 1,500 mg/day | 150= 1,500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q5116 | Trazimera | 10 mg | 120= 1,200 mg/day | 120= 1,200 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q5117 | Kanjinti | 10 mg | 120= 1,200 mg/day | 120= 1,200 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q5118 | Zirabev | 10 mg | 230= 2,300 mg/day | 230= 2,300 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| Q5119 | Ruxience | 10 mg | 150= 1,500 mg/day | 150= 1,500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q5120 | Ziextenzo | 0.5 mg | 12= 6 mg/day | 12= 6 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q5121 | Avsola | 10 mg | 150= 1,500 mg/day | 150= 1,500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q5122 | Nyvepria | 0.5 mg | 12= 6 mg/day | 12= 6 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q5123 | Riabni | 10 mg | 150= 1,500 mg/day | 150= 1,500 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q5124 | Byooviz | 0.1 mg | 10= 1 mg/day | 10= 1 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| Q5125 | Reluko | 1 mcg | 1,800= 1,800 mcg/day | 1,800= 1,800 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q5126 | Alymsys | 10 mg | 230= 2,300 mg/day | 230= 2,300 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| Q5127 | Stimufend | 0.5 mg | 12= 6 mg/day | 12= 6 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q5128 | Cimerli | 0.1 mg | 10= 1 mg/day | 10= 1 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q5129 | Vegzelma | 10 mg | 230= 2,300 mg/day | 230= 2,300 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| Q5130 | Fylnetra | 0.5 mg | 12= 6 mg/day | 12= 6 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q5133 | Tofidence | 1 mg | 1,200= 1,200 mg/day | 1,200= 1,200 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q5134 | Tyruko | 1 mg | 300= 300 mg/day | 300= 300 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q5135 | Tyenne | 1 mg | 1,200= 1,200 mg/day | 1,200= 1,200 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q5136 | Jubbonti / Wyost | 1 mg | 120= 120 mg/day | 120= 120 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q5137 | Wezlana | 1 mg | 90= 90 mg/day | 90= 90 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q5138 | Wezlana | 1 mg | 520= 520 mg/day | 520= 520 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q5140 | Hulio | 1 mg | 160= 160 mg/day | 160= 160 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q5141 | Yuflyma | 1 mg | 160= 160 mg/day | 160= 160 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q5142 | Simlandi | 1 mg | 160= 160 mg/day | 160= 160 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q5143 | Cyltezo | 1 mg | 160= 160 mg/day | 160= 160 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q5144 | Idacio | 1 mg | 160= 160 mg/day | 160= 160 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q5145 | Abrilada | 1 mg | 160= 160 mg/day | 160= 160 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q5146 | Hercessi | 10 mg | 120= 1,200 mg/day | 120= 1,200 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q5147 | Pavblu | 1 mg | 4= 4 mg/day | 4= 4 mg/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Anatomic Consideration | ||||||
| Q5148 | Nypozi | 1 mcg | 1,500= 1,500 mcg/day | 1,500= 1,500 mcg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q5149 | Enzeevu | 1 mg | 4= 4 mg/day | 4= 4 mg/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Anatomic Consideration | ||||||
| Q5150 | Ahzantive | 1 mg | 4= 4 mg/day | 4= 4 mg/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Anatomic Consideration | ||||||
| Q5151 | Epysqli | 2 mg | 600= 1,200 mg/day | 600= 1,200 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q5152 | Bkemv | 2 mg | 600= 1,200 mg/day | 600= 1,200 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q5153 | Opuviz | 1 mg | 4= 4 mg/day | 4= 4 mg/day | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Anatomic Consideration | ||||||
| Q9950 | Lumason | 1 ml | 5= 5 ml/day | 5= 5 ml/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale CMS Policy | ||||||
| Q9956 | Optison | 1 ml | 9= 9 ml/day | 9= 9 ml/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q9957 | Definity | 1 ml | 3= 3 ml/day | 3= 3 ml/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q9958 | Cystografin | 1 ml | 300= 300 ml/day | 600= 600 ml/day | Clinical (MAI 3) | |
| Office edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Prescribing Information. Hospital edit Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale: Clinical: Data. | ||||||
| Q9961 | Conray | 1 ml | 200= 200 ml/day | 200= 200 ml/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q9963 | Gastrografin | 1 ml | 240= 240 ml/day | 240= 240 ml/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q9965 | Omnipaque | 1 ml | 250= 250 ml/day | 300= 300 ml/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| Q9966 | Isovue-200 | 1 ml | 250= 250 ml/day | 250= 250 ml/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q9967 | Isovue-300 | 1 ml | 300= 300 ml/day | 300= 300 ml/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q9968 | Provayblue | 1 mg | 200= 200 mg/day | 200= 200 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Clinical: Data | ||||||
| Q9982 | Vizamyl | per study dose, up to 5 millicuries | 1 | 1 | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Nature of Service/Procedure | ||||||
| Q9983 | Neuraceq | per study dose, upto 8 mci | 1 | 1 | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Nature of Service/Procedure | ||||||
| Q9991 | Sublocade | less than or equal to 100 mg | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| Q9992 | Sublocade | greater than 100 mg | 1 | 1 | Policy (MAI 2) | |
| Edit type Date of Service Edit: Policy (MAI 2): Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds. CMS rationale Code Descriptor / CPT Instruction | ||||||
| Q9996 | Pyzchiva | 1 mg | 90= 90 mg/day | 90= 90 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q9997 | Pyzchiva | 1 mg | 520= 520 mg/day | 520= 520 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q9998 | Selarsdi | 1 mg | 520= 520 mg/day | 520= 520 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
| Q9999 | Otulfi | 1 mg | 520= 520 mg/day | 520= 520 mg/day | Clinical (MAI 3) | |
| Edit type Date of Service Edit: Clinical (MAI 3): Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity. CMS rationale Prescribing Information | ||||||
No code matches that. Try a drug name like Keytruda, or a code like J9271.
The Three Edit Types (MUE Adjudication Indicators)
Every MUE carries an adjudication indicator that decides how the limit is enforced, and what your options are after a denial. The Edit Type column in the table uses these.
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MAI 1
Line Edit
Per-line limit: units are checked per claim line; medically necessary units beyond the limit may be billable on separate lines with appropriate modifiers.
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MAI 2
Date of Service Edit: Policy
Absolute per-day limit set by policy or regulation; units above it are not payable, and denials are not appealable on medical-necessity grounds.
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MAI 3
Date of Service Edit: Clinical
Per-day limit based on clinical expectations; excess units are denied but may be appealed with documentation of medical necessity.
Worked example: Abraxane (J9264) bills per 1 mg, so its practitioner-office MUE of 800 units caps a day's billing at 800 × 1 mg, not that many vials or doses. Convert an administered dose to billing units with the billing calculator before comparing it with the limit.
Frequently Asked Questions
What is a Medically Unlikely Edit (MUE)?
An MUE is a daily cap. It is the most units of a billing code that Medicare expects for one patient in a single day. CMS publishes the caps, and the claims system enforces them automatically. If a claim line goes over the cap, the whole line is denied before anyone reviews it.
What is denial code CO-151, and how do MUEs cause it?
CO-151 is the denial code that usually appears when a claim trips an MUE. It means the information on the claim does not support billing that many units. In plain terms: the line went over the daily cap, so the whole line was denied. Because it is a “CO” (contractual obligation) denial, the practice absorbs the cost; the patient cannot be billed for it. Start by looking the code up in the table above to see the cap you were measured against.
Can an MUE denial be appealed?
It depends on the edit type shown in the table.
Clinical edits (MAI 3) can be appealed: send documentation showing why the patient needed that many units. Policy edits (MAI 2) are firm: you can file an appeal, but Medicare will not pay above the cap, whatever the medical reason. Line edits (MAI 1) are counted per claim line: medically necessary extra units can go on separate lines with the right modifiers.
Are MUE limits counted in doses or in billing units?
Billing units, not doses or vials. Every code has its own unit size. If a code bills per 1 mg and its MUE is 800, the cap is 800 mg per day. If the code bills per 10 mg instead, the same 800 allows 8,000 mg. Always convert the dose you gave into billing units before comparing it to the cap.
Why do some codes show no published MUE?
CMS keeps some MUE values secret to protect against fraud and abuse. Those hidden caps are still enforced on claims; they just are not published. So a code with no published MUE does not mean unlimited billing. It only means the cap is not public.
What does an MUE of 0 mean?
A zero means Medicare will not pay for the code in that setting at all. CMS uses zero when a code is invalid, already bundled into another payment, excluded by law, or otherwise not covered. It is a real published value, not missing data, and a code can have a normal cap in one setting and a zero in the other.
Do commercial payers use Medicare MUEs?
Usually, yes. Large private insurers, including UnitedHealthcare and Cigna, build their own daily-limit rules on the CMS MUE tables. So the cap matters even when the claim is not going to Medicare. The details can differ by payer, so check the specific policy.
How often do MUE values change?
Four times a year. New files take effect January 1, April 1, July 1, and October 1. This page rebuilds from the current published file, so the caps shown are the ones in force. The current file took effect July 1, 2026.
Related Resources
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Billing Calculator
Convert a dose to billing units and price the claim line.
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HCPCS Modifiers
Two-character codes appended to a HCPCS code to add billing detail.
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Drug Wastage: JZ & JW
How to bill discarded drug amounts from single-dose containers.
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Glossary
Plain-English definitions of buy-and-bill billing and coding terms.
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HCPCS Code Lookup
Search any HCPCS drug code for its descriptor, NDC packages, and pricing.
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Place of Service Codes
CMS two-digit codes for where a service was furnished, reported in box 24B.
