What documentation does Blue Cross NC require for CPT J0897?

Member benefit and eligibility verification; Blue Cross NC program-specific prior plan approval documentation; Clinical records supporting the requested service when requested by Blue Cross NC or its vendor

What if Blue Cross NC denies the PA for CPT J0897?

Appeal in writing within 60 days, citing the specific clinical policy criteria the case meets and attaching supporting documentation. Many denials are reversed on first-level appeal when the criteria language is mirrored.

Prior Authorization

Blue Cross NC Prior Authorization for CPT J0897

Injection, denosumab, 1 mg; EviCore Medical Oncology Program for oncology diagnoses · Standard commercial plans

Prior authorization REQUIREDState-specific policyLast verified May 9, 2026 · Reviewed by the D3rx Clinical Billing Team

Source

Blue Cross NC Commercial CPT/HCPCS Prior Plan Approval Search

Not medical advice. PA policies change frequently. Always confirm against the payer's current policy before submitting. d3rx pulls directly from publicly published policy PDFs and refreshes daily.

Clinical criteria

Blue Cross NC commercial CPT/HCPCS prior plan approval search lists J0897 as requiring prior approval for North Carolina commercial context, current as of 2026-05-09. Program label(s): MHK. Source description(s): Injection, denosumab, 1 mg (Prolia/Xgeva) (for all indications). Verify member benefits, BlueCard/home-plan context, FEP, Medicare, Medicaid, and program-specific requirements before submission. This listing is not a payment, coverage, or medical-necessity guarantee.

Documentation checklist

✓Member benefit and eligibility verification
✓Blue Cross NC program-specific prior plan approval documentation
✓Clinical records supporting the requested service when requested by Blue Cross NC or its vendor

2026 Medicare rate for CPT J0897

CPT J0897 is not priced under the 2026 Medicare Physician Fee Schedule (status E) — drugs/biologicals price under ASP and lab tests under the CLFS. See the CPT J0897 code page for pricing detail.

How to submit the PA

1Verify the requirement against the current clinical policy linked above.
2Gather documentation: Member benefit and eligibility verification, Blue Cross NC program-specific prior plan approval documentation, Clinical records supporting the requested service when requested by Blue Cross NC or its vendor.
3Submit via the payer's provider portal or designated PA channel.
4Document the reference number and follow up within 5 business days if no determination is received.

FAQ

Does Blue Cross NC require prior authorization for CPT J0897?: Yes. Blue Cross NC requires prior authorization for CPT J0897 (Injection, denosumab, 1 mg; EviCore Medical Oncology Program for oncology diagnoses) under Standard commercial plans per its published clinical policy.
What documentation does Blue Cross NC require for CPT J0897?: Member benefit and eligibility verification; Blue Cross NC program-specific prior plan approval documentation; Clinical records supporting the requested service when requested by Blue Cross NC or its vendor
What if Blue Cross NC denies the PA for CPT J0897?: Appeal in writing within 60 days, citing the specific clinical policy criteria the case meets and attaching supporting documentation. Many denials are reversed on first-level appeal when the criteria language is mirrored.

Other Blue Cross NC PA lookups

CPT J1745 CPT G2211 CPT J3301 CPT J0585 CPT G0402 CPT G0439 CPT G0438 CPT J1885

All Blue Cross NC prior-authorization requirements →

CPT J0897 prior authorization by payer

Blue Cross Blue Shield Cigna Aetna Humana TRICARE Medicare

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