Thank you for your communication regarding potential exclusion of patients who receive intravenous naloxone to treat opioid-induced pruritis, in regard to the CMS819v2 measure. The use of naloxone for opioid-induced pruritus is off-label and experimental. Conventional antipruritic therapy (e.g., nonsedating antihistamines, topical agents) is generally preferable for treatment of opioid-induced pruritis (Becker, 2022; Ganesh, 2007; McNicol, 2003), given that opioid antagonists are likely to antagonize both the desired (i.e., analgesia) and undesired (i.e., pruritis) effects of opioid therapy. In addition, some opioids may be less pruritogenic than others, so it may be prudent to modify the analgesic prescription instead of adding naloxone, and opioid rotation (Tarcatu, 2007) can also be beneficial. Other opioid antagonists, such as nalbuphine, can be effective in the treatment of opioid induced pruritus (Becker, 2022; Jannuzzi, 2016). Specifically, Becker’s review concluded that “for the treatment of neuraxial morphine-induced pruritus, only nalbuphine appears to be consistently effective”, while Jannuzzi’s review concluded that “nalbuphine provided greater efficacy in treating opioid-induced pruritus when compared with placebo, control, or other pharmacologic agents such as diphenhydramine, naloxone, and propofol (with) no attenuation of analgesia or increase in sedation with low-dose nalbuphine treatment.” Given that the use of intravenous naloxone to treat pruritis is uncommon, less preferred compared with other therapeutic options, and essentially undetectable from structured fields in the electronic health record, it is not feasible to add a denominator exclusion for this indication at this time. Thank you for your suggestion, and CMS will continue to monitor the published literature on this topic. References: 1. McNicol, E., Horowicz-Mehler, N., Fisk, R. A., Bennett, K., Gialeli-Goudas, M., Chew, P. W., Lau, J., Carr, D., & Americal Pain Society (2003). Management of opioid side effects in cancer-related and chronic noncancer pain: a systematic review. The journal of pain, 4(5), 231–256. https://doi.org/10.1016/s1526-5900(03)00556-x 2. Tarcatu, D., Tamasdan, C., Moryl, N., & Obbens, E. (2007). Are we still scratching the surface? A case of intractable pruritus following systemic opioid analgesia. Journal of opioid management, 3(3), 167–170. https://doi.org/10.5055/jom.2007.0055 3. Ganesh, A., & Maxwell, L. G. (2007). Pathophysiology and management of opioid-induced pruritus. Drugs, 67(16), 2323–2333. https://doi.org/10.2165/00003495-200767160-00003 4. Jannuzzi RG. Nalbuphine for Treatment of Opioid-induced Pruritus: A Systematic Review of Literature. Clin J Pain. 2016 Jan;32(1):87-93. doi: 10.1097/AJP.0000000000000211. 5. Becker, L. M., Teunissen, A. J. W., & Koopman, J. S. H. A. (2022). Prevention and Treatment of Neuraxial Morphine-Induced Pruritus: A Scoping Review. Journal of pain research, 15, 1633–1645. https://doi.org/10.2147/JPR.S361225