J0717, Injection, certolizumab pegol, 1 mg (code may be used for medicare when drug
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Documentation Required
- Imaging and laboratory/biomarker data used in studies: brain CT or MRI, amyloid PET (e.g., florbetapir), cerebrospinal fluid (CSF) biomarkers (Aβ1-42, total tau, phospho-tau), and APOE ε4 genotyping when reported in trials.
- For some interventional procedures/trials, pre-procedure evaluations included medical/neurological and psychological examinations, depression rating scales (e.g., Montgomery–Asberg Depression Rating Scale), and lumbar puncture with CSF analysis.
- Documentation of prior/concurrent standard therapies (e.g., use of cholinesterase inhibitors and/or memantine) is often recorded in trials and may be relevant when considering investigational add-on therapies.
- None specified in this policy document. (The CPB lists investigational/experimental treatments and codes not covered; it does not define separate documentation requirements for coverage of the listed items.)
- None specified in this document excerpt.
- Precertification/Statement of Medical Necessity (SMN) form as required by Aetna (call/fax numbers provided in policy).
Key Coverage Criteria
- Indication: Crohn’s disease (CD) – for initial therapy, diagnosis of moderately to severely active CD; inadequate response to conventional therapies; Cimzia initiated and titrated per FDA-labeled dosing for CD; not on a systemic targeted immunomodulator for same indication.
- 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.
- None specified. This Clinical Policy Bulletin addresses experimental treatments for Alzheimer's disease and lists treatments considered experimental and investigational (i.e., not established as effective) for this indication.
- No explicit covered indications are stated in this document. The document discusses potential therapeutic use in the following conditions:
- Alzheimer's disease (AD)
- mild cognitive impairment (MCI)
17 Active Policies
UHC-POL-cimzia, Cimzia (Certolizumab Pegol)
UHC-POL-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care
AETNA-CPB-0788, Alzheimer's Disease: Experimental, Investigational, or Unproven Treatments
AETNA-CPB-0761, Certolizumab Pegol (Cimzia)
AETNA-CPB-0602, Intradiscal Procedures
RX501.111, Certolizumab pegol
BCBSIL-RX501.111, Certolizumab Pegol
BCBSIL-ADM1001.034, Specialty Medication Administration Site of Care
BCBSMT-RX501.111, Certolizumab Pegol
BCBSMT-ADM1001.034, Specialty Medication Administration Site of Care
BCBSNM-RX501.111, Certolizumab Pegol
BCBSNM-ADM1001.034, Specialty Medication Administration Site of Care
BCBSOK-RX501.111, Certolizumab Pegol
BCBSOK-ADM1001.034, Specialty Medication Administration Site of Care
UMR-POL-UMR-cimzia, Cimzia (Certolizumab Pegol)
UMR-POL-UMR-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care
SUREST-POL-SUREST-cimzia, Cimzia (Certolizumab Pegol)
Related Codes
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