Radium Ra 223 Dichloride (Xofigo) (CPB 0874, reviewed 2025-12-22)

Immediately: Billing team must implement mandatory precertification requirement for all Xofigo (A9606) claims submitted to Aetna commercial plans. (1) Update billing system to flag all A9606 claims for prior authorization approval before submission. (2) Establish precertification process: direct providers and patients to call (866) 752-7021 or fax (888) 267-3277 with Statement of Medical Necessity (SMN) forms from Specialty Pharmacy Precertification. (3) Create verification checklist in billing/EMR system requiring confirmation of ALL approval criteria before claim submission: (a) patient has symptomatic bone metastases, (b) patient has NO visceral metastatic disease, (c) patient has bilateral orchiectomy OR is using LHRH agonist/antagonist (CPT 54520/54522/54530/54535 or J9202/J9217/J9218/J9219/J9155). (4) Deny claims automatically if precertification not obtained or if patient does not meet clinical criteria. (5) Alert providers that only 6 total injections per course are covered; additional courses (more than 6 injections total) will be denied as experimental. (6) Reject all off-label indications (breast cancer, kidney cancer, lung cancer, multiple myeloma, osteosarcoma without prior 2+ systemic therapies, etc.) as non-covered. Failure to obtain precertification or failure to verify clinical eligibility will result in automatic claim denial.