J0791, Injection, crizanlizumab-tmca, 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
Documentation Required
- Clinical documentation demonstrating the diagnosis or procedure for which the therapy is prescribed.
- Documentation that the therapy is proven effective for the relevant diagnosis (citations or reference to authoritative source or peer-reviewed literature).
- Documentation of the proposed dose, frequency, and duration and citation to at least one authoritative source or FDA-approved labeling supporting that regimen.
- Provider and member must consult the member's benefit plan/summary plan description/contract to determine applicable coverage, exclusions, and limitations.
Key Coverage Criteria
- 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.
- Drug therapy is covered when it is proven effective for the relevant diagnosis or procedure.
- Drug therapy is covered when the proposed dose, frequency, and duration are consistent with recommendations in at least one authoritative source (e.g., FDA labeling, DrugDex, NCCN, MCG).
- Coverage of an FDA-approved drug when prescribed for a use recognized as safe and effective in one or more standard medical reference compendia adopted by the U.S. Department of Health and Human Services.
- Coverage of an FDA-approved drug for an off-label use when medical literature provides support from two articles in major peer-reviewed professional medical journals confirming safety and efficacy for the proposed use.
- Individual is 16 years of age or older
14 Active Policies
UHC-POL-adakveo-crizanlizumab-tmca, Adakveo (Crizanlizumab-Tmca)
UHC-POL-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care
RX501.126, Crizanlizumab-tmca
BCBSIL-RX501.126, Crizanlizumab-tmca
BCBSIL-ADM1001.034, Specialty Medication Administration Site of Care
Related Codes
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