J0202 — Injection, alemtuzumab, 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
- For UB-04 hospital outpatient (Part B) claims, include diagnosis in Box 66 (ICD-10-CM G35.A or G35.C1 where applicable), HCPCS drug code in Field 44, narrative (Field 80 or electronic equivalent) containing NDC, trade and generic drug name, dose administered, and route of administration.
- For CMS-1500 (Part B) claims, include diagnosis in Box 21 (ICD-10-CM G35.A or G35.C1 where applicable), HCPCS drug code in Box 24D, and narrative in Box 19 (or electronic equivalent) with NDC, trade and generic drug name, dose administered, and route of administration.
- Include HCPCS J0202 (Injection, alemtuzumab 1 mg) for applicable dates of service and list the single-use vial NDC 58468-0200-1 or 58468-0200-01 in the claim narrative.
- Claims must reflect administered dose as 12 mg per date of service consistent with FDA labeling; discrepancies in administered dose, wastage, or NDC will result in claim rejection.
Key Coverage Criteria
- Treatment of relapsing forms of multiple sclerosis with documented diagnosis code ICD-10-CM G35.A or G35.C1 on the claim for dates of service on or after 10/01/2015.
- Therapy must follow FDA-labeled dosing: 12 mg IV once daily for 5 consecutive days for the first course, then 12 mg IV once daily for 3 consecutive days approximately one year after the first course.
- Lemtrada (alemtuzumab) is proven and medically necessary for treatment of relapsing forms of multiple sclerosis (MS) (e.g., relapsing-remitting MS, active secondary-progressive MS) when all of the following criteria are met:
- Diagnosis of relapsing forms of multiple sclerosis (MS) (e.g., relapsing-remitting MS, active secondary-progressive MS).
- Treatment‑naïve to alemtuzumab: Patient has history of failure following a trial for at least 4 weeks or history of intolerance to at least two of the following: interferon β-1a (Avonex or Rebif), interferon β-1b (Betaseron or Extavia), glatiramer acetate (Copaxone or Glatopa), dimethyl fumarate (Tecfidera), teriflunomide (Aubagio), fingolimod (Gilenya), peginterferon beta-1a (Plegridy), natalizumab (Tysabri), ocrelizumab (Ocrevus), rituximab (Riabni, Rituxan, Ruxience, & Truxima), siponimod (Ma [...]
- Patient has not been previously treated with alemtuzumab (for initial treatment).
11 Active Policies
AETNA-CPB-0598 — Lung Transplantation
AETNA-CPB-0732 — Guillain-Barre Syndrome Treatments
UHC-POL-lemtrada-alemtuzumab — Lemtrada (Alemtuzumab)
A55310 — Billing and Coding: Instructions for Lemtrada (alemtuzumab) When Used in the Treatment of Relapsing Multiple Sclerosis
UMR-POL-UMR-lemtrada-alemtuzumab — Lemtrada (Alemtuzumab)
Related Codes
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