J0606 — Injection, etelcalcetide, 0.1 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
- Documentation that prescribing or consultation was by an endocrinologist or nephrologist.
- Documentation of dosing consistent with FDA-approved labeling (dose and administration schedule).
- Documentation that corrected serum calcium is at or above the lower limit of normal prior to Parsabiv initiation.
- For continuation/reauthorization: documentation of a reduction in serum calcium from baseline.
Key Coverage Criteria
- Secondary hyperparathyroidism with chronic kidney disease in patients on dialysis (adult patients on hemodialysis).
- Initial therapy when ALL of the following are met: Diagnosis of secondary hyperparathyroidism with chronic kidney disease; Patient is on dialysis; Patient is not receiving Parsabiv (etelcalcetide) in combination with Sensipar (cinacalcet hydrochloride); Prescribed by or in consultation with an endocrinologist or nephrologist; Dosing is in accordance with the United States Food and Drug Administration approved labeling; Initial authorization will be for no longer than 12 months.
- Medically necessary (initial) when ALL of the following are met: Diagnosis of secondary hyperparathyroidism with chronic kidney disease; Patient is on dialysis; History of failure, contraindication, or intolerance to one phosphate binder (e.g., PhosLo, Fosrenol, Renvela, Renagel, etc.); History of failure, contraindication, or intolerance to one vitamin D analog (e.g., calcitriol, Hectorol, Zemplar, etc.); History of failure of maximum tolerated dosage, adverse reaction, or contraindication to S [...]
- Continuation therapy (reauthorization) when ALL of the following are met: Documentation of a reduction in serum calcium from baseline; Patient is not receiving Parsabiv in combination with Sensipar (cinacalcet hydrochloride); Prescribed by or in consultation with an endocrinologist or nephrologist; Dosing per FDA labeling; Reauthorization will be for no longer than 12 months.
- Applicable diagnosis codes referenced (for coverage consideration): E21.1; N25.81; N18.1; N18.2; N18.30; N18.31; N18.32; N18.4; N18.5; N18.9.
3 Active Policies
UHC-POL-parsabiv-etelcalcetide — Parsabiv (Etelcalcetide)
UMR-POL-UMR-parsabiv-etelcalcetide — Parsabiv (Etelcalcetide)
SUREST-POL-SUREST-parsabiv-etelcalcetide — Parsabiv (Etelcalcetide)
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.