J0638 — Injection, canakinumab, 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 initial therapy where specified: diagnosis 'by, or in consultation with, a rheumatologist or immunologist with expertise in the diagnosis' (policy text).
- For continuation of therapy: 'Documentation of positive clinical response to Ilaris therapy.'
- FMF: medical record evidence of 'History of failure, contraindication, or intolerance to colchicine.'
- Gout flares: medical record evidence of 'History of contraindication, intolerance, or treatment failure with both of the following: Colchicine; Non-steroidal anti-inflammatory drugs (NSAIDs)' and a provider attestation that 'the patient is not an appropriate candidate for systemic corticosteroids.'
Key Coverage Criteria
- Cryopyrin-associated periodic syndromes (CAPS), including familial cold autoinflammatory syndrome (FCAS) and Muckle-Wells syndrome (MWS).
- Tumor necrosis factor (TNF) receptor-associated periodic syndrome (TRAPS).
- Hyperimmunoglobulin D (Hyper-IgD) syndrome (HIDS) / Mevalonate kinase deficiency (MKD).
- Familial Mediterranean fever (FMF).
- Active Still's disease, including adult-onset Still's disease (AOSD) and systemic juvenile idiopathic arthritis (SJIA).
- Symptomatic treatment of gout flares in adults in whom non-steroidal anti-inflammatory drugs (NSAIDs) and colchicine are contraindicated, are not tolerated, or do not provide an adequate response, and in whom repeated courses of corticosteroids are not appropriate.
14 Active Policies
UHC-POL-ilaris-canakinumab — Ilaris (Canakinumab)
UHC-POL-provider-administered-drugs-soc — Provider Administered Drugs – Site of Care
UMR-POL-UMR-ilaris-canakinumab — Ilaris (Canakinumab)
UMR-POL-UMR-provider-administered-drugs-soc — Provider Administered Drugs – Site of Care
SUREST-POL-SUREST-ilaris-canakinumab
Related Codes
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