J0174, Lecanemab-irmb, for intravenous injection, 1 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Medical records/chart notes documenting diagnosis consistent with NIA-AA criteria (MCI due to AD or mild dementia due to AD) for initial therapy; for continuation documentation that diagnosis of Alzheimer's disease persists (or documentation of progression to moderate/severe with prescriber attestation of shared decision-making).
- Submission of medical records documenting one of the following cognitive test scores for initiation: Mini-Mental State Examination (MMSE) score of 20 to 30; Montreal Cognitive Assessment (MoCA) score of 17 to 30; OR Saint Louis University Mental Status (SLUMS) score of 17 to 30.
- Submission of medical records documenting presence of amyloid beta pathology by one of the following: positive amyloid PET brain imaging; OR cerebrospinal fluid (CSF) biomarker testing documenting abnormalities suggestive of beta-amyloid accumulation (e.g., Aß42/40 ratio, p-tau181/Aß42 ratio, t-tau/Aß42 ratio).
Key Coverage Criteria
- Intravenous administration of Leqembi (lecanemab-irmb) by a healthcare professional for the treatment of Alzheimer's disease when all applicable criteria below are met.
- Initial therapy for patients with a diagnosis (based on NIA-AA criteria) of either: Mild cognitive impairment (MCI) due to Alzheimer's disease; or Mild dementia due to Alzheimer's disease.
- Continuation therapy for patients with a diagnosis of Alzheimer's disease (including those who remain MCI or mild dementia due to AD, or those who have progressed to moderate or severe dementia when prescriber attests patient shared in decision-making to continue Leqembi).
- Treatment only when presence of amyloid beta pathology has been confirmed (see documentation requirements).
- Treatment when baseline brain MRI has been completed within 12 months prior to initiating treatment and required follow-up MRI(s) are completed after initiation as specified in policy.
- Leqembi dosing when given must follow the United States FDA approved labeling.
13 Active Policies
UHC-POL-leqembi, Leqembi (Lecanemab-Irmb)
AETNA-CPB-0349, Alzheimer's Disease Tests
RX501.152, Lecanemab-irmb
BCBSIL-RX501.152, Lecanemab-irmb
BCBSIL-ADM1001.034, Specialty Medication Administration Site of Care
Related Codes
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