Prior authorization valid for a single administration

Prior authorization validity is issued initially for one administration of Hicon and prior authorization may NOT be renewed; additional administrations beyond the single authorization are not approved under renewal.

Verify Medicare coverage, NCDs/LCDs, and local guidance

For Medicare patients, providers should verify Medicare coverage and any applicable NCDs/LCDs or Local Coverage Articles before billing by checking the CMS coverage database and contractor guidance.

• Search for NCD/LCD/LCA documents: https://www.cms.gov/medicare-coveragedatabase/search.aspx
• Follow applicable Medicare Benefit Policy Manual and local contractor rules

Require failure or intolerance to anti‑thyroid medication for hyperthyroidism

For hyperthyroidism indications, the member must have failed anti-thyroid medication therapy or have documented intolerance or a contraindication to anti-thyroid medications before I-131 therapy is approved.

• Failure/intolerance/contraindication applies to Graves disease–related hyperthyroidism per policy language

Confirm prerequisites and provide supporting clinical documentation

Ensure all required pre-treatment prerequisites and documentation are met and provided to support medical necessity and safe administration.

• Confirm other causes of hyperthyroidism are ruled out (e.g., thyroid malignancy, TSH‑secreting pituitary tumors)
• Verify patient is ≥18 years old and females of reproductive potential have a negative pregnancy test prior to treatment
• Confirm adherence to low‑iodide diet and discontinuation of anti‑thyroid medications as specified

Billing codes and required supporting documentation

Bill using HCPCS code A9517 (capsule) or A9530 (solution) per millicurie and include supporting documentation; use the Hicon NDC 65174-0880-XX for vial products as applicable.

• HCPCS: A9517 and A9530 (1 billable unit = 1 mCi)
• NDC: Hicon vials 65174-0880-XX (listed vial strengths in policy)
• Include documentation supporting diagnosis, thyroidectomy status (if applicable), pregnancy test results for females of reproductive potential, and adherence to pre-treatment requirements

Use supported ICD‑10 codes from Appendix 1 to substantiate medical necessity

Use the ICD‑10 diagnosis codes listed in Appendix 1 (e.g., C73; E05.00–E05.21; Z85.850) on claims to support medical necessity for Hicon therapy.

• Appendix 1 diagnoses include C73, E05.00–E05.21, and Z85.850

Claims edits may trigger denial for unmet diagnosis or dosing criteria

Pre‑payment claims edits are applied to diagnosis criteria and to maximum units per dose; claims that do not meet the policy’s diagnosis or dosing edits (including HCPCS unit limits) may be denied.

• Edits include diagnosis matching Appendix 1 and maximum units per administration (see dosing limits)
• Ensure billed units (mCi) align with policy maximums to avoid edit-triggered denials

Follow CMS NCD/LCD requirements for Medicare coverage

Noncompliance with applicable Medicare NCDs or LCDs (where they exist) and related contractor guidance may affect Medicare coverage determinations for Hicon; follow CMS and MAC requirements when treating Medicare beneficiaries.

• Refer to the Medicare Benefit Policy Manual, Chapter 15 §50, and search the CMS coverage database for NCDs/LCDs/LCA using the provided link