Does J0174 require prior authorization?

No, J0174 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for J0174?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

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).

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.

AETNA-CPB-0349 — Alzheimer's Disease Tests

UHC-POL-leqembi — Leqembi (Lecanemab-Irmb)

UMR-POL-UMR-leqembi — Leqembi (Lecanemab-Irmb)

SUREST-POL-SUREST-leqembi — Leqembi (Lecanemab-Irmb)

BCBSIL-RX501.152 — Lecanemab-irmb

Ask Verity about documentation requirements, denial risks, or coverage in your state.