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
- No documentation requirements are specified in the provided document text.
- Documentation of patient's age (showing patient is 16 years of age or older)
- Medical record documentation of diagnosis of sickle cell disease, including genotype when applicable (e.g., HbSS, HbSC, sickle beta 0 thalassemia, sickle beta + thalassemia)
- Documentation that the patient is transitioning from Oxbryta (voxelotor) to Adakveo, if applicable
Key Coverage Criteria
- Adakveo is proven and/or medically necessary to reduce the frequency of vasoocclusive crises in patients with sickle cell disease who meet all of the following criteria:
- Patient is 16 years of age or older
- D57.1 - Sickle-cell disease without crisis
- D57.2 - Sickle-cell/Hb-C disease
- D57.20 - Sickle-cell/Hb-C disease without crisis
- Diagnosis of a sickle cell disease, including, but not limited to, homozygous hemoglobin S (HbSS), sickle hemoglobin C disease (HbSC), sickle beta 0 thalassemia, and sickle beta + thalassemia
14 Active Policies
UHC-POL-adakveo-crizanlizumab-tmca — Adakveo (Crizanlizumab-Tmca)
UHC-POL-provider-administered-drugs-soc — Provider Administered Drugs – Site of Care
UMR-POL-UMR-adakveo-crizanlizumab-tmca — Adakveo (Crizanlizumab-Tmca)
UMR-POL-UMR-provider-administered-drugs-soc — Provider Administered Drugs – Site of Care
Related Codes
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