J0257 — Injection, alpha 1 proteinase inhibitor (human), (glassia), 10 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
- Documentation of diagnosis of congenital alpha1-antitrypsin deficiency confirmed by genotype/phenotype: Pi*ZZ, Pi*Z(null), Pi*(null)(null) protein phenotypes (homozygous) or other disease-causing alleles (e.g., Pi [Malton, Malton])
- Laboratory documentation of circulating serum alpha1-antitrypsin (AAT) concentration < 11 µmol/L, with method and equivalent values if applicable (corresponds to < 80 mg/dl if measured by radial immunodiffusion or < 57 mg/dl if measured by nephelometry)
- Documentation of continued optimal conventional treatment for emphysema (examples provided: bronchodilators, supplemental oxygen if necessary)
- Documentation that the patient is a current nonsmoker (smoking status)
Key Coverage Criteria
- Alpha1-proteinase inhibitors (Aralast NP™, Glassia™, Prolastin®-C, and Zemaira®) are proven for chronic augmentation and maintenance therapy of patients with emphysema due to congenital deficiency of alpha1-proteinase inhibitor (A1-PI), also known as alpha1-antitrypsin (AAT) deficiency.
- Alpha ${ }_{1}$-Proteinase Inhibitor ( $9A19$-PI) Deficiency [i.e., Alpha ${ }_{1}$-Antitrypsin (AAT) Deficiency]
- Alpha1-proteinase inhibitors (Aralast NP™, Glassia™, Prolastin®-C, and Zemaira®) are medically necessary for the treatment of emphysema due to congenital deficiency of alpha1-proteinase inhibitor (A1-PI) in patients who meet all of the following criteria:
- For initial therapy, all of the following:
- Diagnosis of congenital alpha1-antitrypsin deficiency confirmed by one of the following:
- Pi*ZZ, Pi*Z(null) or Pi*(null)(null) protein phenotypes (homozygous); or
6 Active Policies
UHC-POL-alpha1-proteinase-inhibitors — Alpha1-Proteinase Inhibitors
AETNA-CPB-0145 — Alpha 1-Proteinase Inhibitors
UHC-POL-provider-administered-drugs-soc — Provider Administered Drugs – Site of Care
UMR-POL-UMR-alpha1-proteinase-inhibitors — Alpha1-Proteinase Inhibitors
UMR-POL-UMR-provider-administered-drugs-soc
Related Codes
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