Quick answer
J9317
What Medicare pays for Trodelvy (2026 Q2)
Once a claim carries a covered diagnosis, Medicare Part B reimburses the drug at the ASP + 6% payment limit. Current allowed amounts per billing unit:
| HCPCS | Description | Per unit | Allowed (ASP + 6%) |
|---|---|---|---|
| J9317 | Sacituzumab govitecan-hziy | 2.5 mg | $36.797 |
Source: CMS ASP Drug Pricing File, 2026 Q2. Payment = ASP + 6% per unit; multiply by units billed (watch JZ/JW wastage). Your patient's share is typically 20% after the deductible. Estimate the full cost & patient out-of-pocket →
Trodelvy is a physician-administered biologic billed under Medicare Part B (not the Part D pharmacy benefit). Under Part B, Medicare pays the practice for the drug (HCPCS J9317) plus its administration — but only when the claim's diagnosis (ICD-10) code supports medical necessity. Each MAC publishes the specific covered diagnoses in a Billing & Coding Article; a claim with a diagnosis outside that list is typically denied as not medically necessary (CO-50).
Covered ICD-10 diagnoses for Trodelvy
The 5 ICD-10 codes below are the FDA-approved indications for J9317 — the labeled uses Medicare generally pays for under medical necessity — grouped by condition. Use the filter to find a specific code or condition.
Triple-Negative Breast — 2 diagnoses (applies to J9317)
Neoplasms (2)
| ICD-10 | Covered diagnosis |
|---|---|
| C50.911 | Malignant neoplasm of unspecified site of right female breast |
| C50.919 | Malignant neoplasm of unspecified site of unspecified female breast |
Urothelial Carcinoma — 1 diagnoses (applies to J9317)
Neoplasms (1)
| ICD-10 | Covered diagnosis |
|---|---|
| C67.9 | Malignant neoplasm of bladder, unspecified |
Encounter — 1 diagnoses (applies to J9317)
Factors influencing health status (1)
| ICD-10 | Covered diagnosis |
|---|---|
| Z51.11 | Encounter for antineoplastic chemotherapy |
Breast Cancer — 1 diagnoses (applies to J9317)
Neoplasms (1)
| ICD-10 | Covered diagnosis |
|---|---|
| C50.9 | Malignant neoplasm of breast of unspecified site |
How to use this list when billing
Put a medically necessary, FDA-indicated diagnosis from the list above on the claim line with J9317, match the correct product code and units (check JZ/JW wastage), and document medical necessity. Because there's no drug-specific LCD, coverage is judged per medical necessity by your MAC; an off-label use can still be covered if supported by an approved drug compendium.
LCD vs. Billing & Coding Article vs. NCD
An LCD (Local Coverage Determination) is a MAC's policy on whether a service is reasonable and necessary in its region, and its companion Billing & Coding Article holds the covered ICD-10 and HCPCS code lists. A NCD (National Coverage Determination), where one exists, applies nationwide. Trodelvy has no drug-specific LCD or Article, so there is no published covered-code list — it's covered under the general Part B drug benefit per medical necessity, and the FDA-approved indications above are the practical starting point.
Common Trodelvy denial reasons
| What you see | Why | Fix |
|---|---|---|
| CO-50 — not medically necessary | Diagnosis the MAC doesn’t accept as medically necessary | Bill a medically necessary FDA-indicated diagnosis from the list above; document necessity (compendium cite for off-label) |
| Diagnosis/units mismatch | Right dx but wrong product code or unit count | Match the J/Q code and units to the drug actually given (check JZ/JW wastage) |
| Off-label denial | Indication isn't FDA-labeled and isn't compendium-supported | Cite an approved compendium (e.g. DrugDex/NCCN) or appeal with literature |
| Self-administered (SAD) denial | Drug is on your MAC's self-administered exclusion list | Check the SAD list — it may be Part D, not Part B |
Frequently asked questions
- Is Trodelvy covered by Medicare?
- Yes. Trodelvy (J9317) is covered under Medicare Part B as a physician-administered drug when billed for a medically necessary indication. There is no drug-specific Local Coverage Determination (LCD) for it, so coverage is determined per medical necessity by your MAC; the FDA-approved indications below are the starting point.
- What diagnoses are covered for Trodelvy (J9317)?
- Medicare does not publish a drug-specific covered-diagnosis list for J9317. The 5 ICD-10 codes on this page are the FDA-approved indications — the labeled uses Medicare will generally pay for under medical necessity. Off-label uses may be covered if supported by an approved compendium.
- Which Medicare policy covers Trodelvy?
- No drug-specific LCD or Billing & Coding Article exists for Trodelvy. It's covered under the general Medicare Part B drug benefit per medical necessity, as judged by your Medicare Administrative Contractor (MAC).
- Why was my Trodelvy claim denied as not medically necessary?
- The most common cause is a diagnosis the MAC doesn't consider medically necessary for J9317. Bill a covered/FDA-approved indication from the list below, document medical necessity, and confirm any local guidance with your MAC.
Related references
Covered is only half the answer.
You know the diagnosis is payable. Now quote the patient before the visit and catch underpayments: get Trodelvy's exact Medicare allowed amount, your payer's rate vs. ASP+6%, and the patient's out-of-pocket — in about 30 seconds, free.
Estimate Trodelvy cost & patient owe →Source & verification
- Source
- FDA-approved indications (Drugs@FDA labeling) mapped to ICD-10-CM. No drug-specific Medicare LCD/Article exists for Trodelvy — Part B coverage is determined per medical necessity by your MAC.
- CMS article last revised
- n/a — the most recent revision CMS has published for this article.
- Page last reviewed by CareCost
- Jun 29, 2026 (coverage data retrieved 2026-06-28; we re-verify against CMS quarterly).
- Code licensing
- ICD-10-CM codes are public domain (CMS/CDC). CPT® codes are AMA-copyrighted and are intentionally not listed here — see the administration-code reference for those.
- Not advice
- This is general billing reference, not legal or billing advice. Always verify against the LCD/Article that applies to your MAC and patient.
- How we build this
- Compiled programmatically from the CMS Coverage API and reviewed by the CareCost Estimate editorial team against the source article. See our methodology and editorial policy.
- Spotted an error?
- Email editorial@carecostestimate.com.