PA requirements will be added to the following codes:

• A9543 Injection, Yttrium Y-90 ibritumomab tiuxetan (Zevalin)
• A9590 Injection, Iodine I-131, iobenguane, 1 mCi (Azedra)
• A9513 Injection, Lutetium Lu 177, dotatate, therapeutic, 1 millicurie (Lutathera)
• A9606 Injection, Radium ra-223 dichloride, therapeutic, per microcurie (Xofigo)

Effective 04/01/2021 the above codes will require an auth.

Providers have 2 ways to order a PA:

• Web: https://www.availity.com*
• Phone: 1-800-282-4548

Federal and state law, as well as state contract language, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage.