Coding and Claims Processing
Forms and Documents
 
The information below includes a directory of downloadable sample forms and documents to support successful claims submissions — including examples of claim forms and potential codes that may be appropriate when billing for Neulasta® (pegfilgrastim) and related services. Properly coding your claim forms will help facilitate timely claims processing and reduce the risk of having claims denied.
 
Physicians or providers are responsible for selecting the appropriate codes used in filing a claim. Codes should be based on the patient's diagnosis and the items and services furnished by the physician or the provider.
 




Statement of Medical Necessity for Neutropenia Therapy

Statement of Medical Necessity for Neutropenia Therapy
  • Some insurers will require additional information justifying the medical necessity of Neulasta® (pegfilgrastim) therapy.
  • Statements of Medical Necessity provide basic information about an individual patient's condition.
Statement of Medical Necessity for Neutropenia Therapy  Statement of Medical Necessity for Neutropenia Therapy 

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Sample Letter of Medical Necessity

Sample Letter of Medical Necessity
  • Letters of Medical Necessity provide a detailed explanation of why Neulasta® therapy is appropriate for the medical condition described.
  • The attached Sample Letter of Medical Necessity provides a detailed explanation of why Neulasta® therapy is appropriate for the medical condition described as well as potential rationale statements for communications with insurers.
Sample Letter of Medical Necessity  Sample Letter of Medical Necessity

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Sample Letter of Appeal

Letter of Appeal
  • If an insurer denies a claim as "not medically necessary," it is up to the physician/provider to demonstrate the medical necessity of the treatment.
  • In the case of Medicare, it may be appropriate/necessary to submit a written appeal to the denied claim, providing written justification on why Neulasta® (pegfilgrastim) was used.
Letter of Appeal Sample Letter of Appeal 

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Sample Letter to Local CAC Member

Sample Letter to Local CAC Member  Sample Letter to Local CAC Member 

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FDA Approval Letter

FDA Approval Letter
FDA Approval Letter FDA Approval Letter
   

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NDC Billing Sheet

NDC Billing Sheet
FDA Approval Letter NDC Billing Sheet

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Fact Sheet

Fact Sheet
Fact Sheet Fact Sheet

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Authorization to Disclose Health Information

Authorization to Disclose Health Information
Authorization to Disclose Health Information  Authorization to Disclose Health Information

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Neulasta® Insurance Verification Request Form

Neulasta® Insurance Verification Request Form
   Neulasta® Insurance Verification Request Form 

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Issue Briefs

Medicare Part D (Oncology)
Patient Support (Oncology)
Hospital Outpatient (Oncology)

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*CPT® five-digit codes, nomenclature, and other data are ©2005 American Medical Association. All rights reserved. No fee schedules, basic unit, relative values, or related listings are included in CPT®. The AMA assumes no liability for the data contained herein.


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Indications

Neulasta® Indication

Neulasta® is indicated to decrease the incidence of infection, as manifested by febrile neutropenia, in patients with nonmyeloid malignancies receiving myelosuppressive anticancer drugs associated with a clinically significant incidence of febrile neutropenia.

Important Product Safety Information

Splenic rupture (including fatal cases), acute respiratory distress syndrome, and sickle cell crises have been reported. Allergic reactions, including anaphylaxis, have also been reported. The majority of these reactions occurred upon initial exposure. However, in rare cases, allergic reactions, including anaphylaxis, recurred within days after discontinuing anti-allergic treatment.
In a placebo-controlled trial, bone pain occurred at a higher incidence in Neulasta®-treated patients as compared to placebo-treated patients (31% vs 26%). The most common adverse events reported in either placebo- or active-controlled trials were consistent with the underlying cancer diagnosis and its treatment with chemotherapy, with the exception of bone pain.