J0224, Injection, lumasiran, 0.5 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
Key Coverage Criteria
- Indication: Oxlumo (Lumasiran) is covered for treatment of PH1 in patients who meet all of the following initial-therapy criteria: diagnosis of PH1; not receiving Oxlumo with Rivfloza; dosing per FDA labeling; initial authorization up to 12 months. For continuation, require positive clinical response, not receiving Rivfloza with Oxlumo, dosing per FDA labeling, and reauthorization up to 12 months.
- Covered when hospital outpatient facility infusion services for specialty medications and IVIG/SCIG therapy are considered medically necessary and the member meets the specific clinical criteria described in the policy.
- This policy addresses only the determination of medical necessity for the hospital outpatient setting for infusion and injectable therapy; the medical necessity of the pharmacologic or biologic medication itself may be reviewed separately.
- Requests for select medications intended for administration in a hospital outpatient setting will be directed to a preferred alternative site of care (non-hospital affiliated outpatient facility or home).
- This policy addresses only the determination of medical necessity for the hospital outpatient setting for infusion and injectable therapy; the medical necessity of the pharmacologic or biologic medication itself may be reviewed separately.
- Requests for select medications intended for administration in a hospital outpatient setting will be directed to a preferred alternative site of care (non-hospital affiliated outpatient facility or home).
9 Active Policies
UHC-POL-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care
BCBSIL-ADM1001.034, Specialty Medication Administration Site of Care
BCBSMT-ADM1001.034, Specialty Medication Administration Site of Care
BCBSNM-ADM1001.034, Specialty Medication Administration Site of Care
BCBSOK-ADM1001.034, Specialty Medication Administration Site of Care
Related Codes
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