38204
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
1.95
Facility
$86.17
Non-Facility
$86.17
Documentation Required
- Documented pretreatment serum AAT level < 11 micromol/L (80 mg/dL by radial immunodiffusion or 50 mg/dL by nephelometry).
- Documented pretreatment post-bronchodilation FEV1 value ≥ 25% and ≤ 80% of predicted (forced expiratory volume in 1 second, post-bronchodilation).
- Documented AAT genotype/phenotype: PiZZ, PiZ (null), or Pi (null, null) (homozygous) AAT deficiency or other phenotype/genotype associated with serum AAT < 11 micromol/L.
- Documentation that the member does not have the PiMZ or PiMS AAT deficiency.
Key Coverage Criteria
- Aetna considers alpha 1-proteinase inhibitor (e.g., Aralast NP, Glassia, Prolastin-C, and Zemaira) therapy medically necessary for the treatment of emphysema due to alpha 1-antitrypsin (AAT) deficiency when all of the following criteria are met:
- The member’s pretreatment serum AAT level is less than 11 micromol/L (80 mg/dL by radial immunodiffusion or 50 mg/dL by nephelometry);
- The member’s pretreatment post-bronchodilation forced expiratory volume in 1 second (FEV1) is greater than or equal to 25% and less than or equal to 80% of the predicted value;
- The member has a documented PiZZ, PiZ (null), or Pi (null, null) (homozygous) AAT deficiency or other phenotype or genotype associated with serum AAT concentrations of less than 11 micromol/L (80 mg/dL by radial immunodiffusion or 50 mg/dL by nephelometry);
- The member does not have the PiMZ or PiMS AAT deficiency.
- Continuation: Aetna considers continuation of alpha 1-proteinase inhibitor (Aralast NP, Glassia, Prolastin-C, and Zemaira) therapy medically necessary for treatment of emphysema due to alpha 1-antitrypsin (AAT) deficiency when the member is experiencing beneficial clinical response from therapy.
20 Active Policies
AETNA-CPB-0145 — Alpha 1-Proteinase Inhibitors
AETNA-CPB-0195 — Erythropoiesis Stimulating Agents
AETNA-CPB-0495 — Hematopoietic Cell Transplantation for Hodgkin's Disease
AETNA-CPB-0638 — Donor Lymphocyte Infusion
AETNA-CPB-0190 — Stem Cells for Hematopoietic Cell Transplant
Related Codes
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