J0801 — Injection, corticotropin (acthar gel), up to 40 units
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
- Dosing documentation consistent with FDA approved labeling (dosing must be in accordance with FDA labeling).
- Provider attestation that the caregiver is not able to be trained or is physically unable to administer the drug (required for both infantile spasms and opsoclonus-myoclonus); provider must submit an explanation.
- Documentation of the diagnosis (infantile spasms/West Syndrome or opsoclonus-myoclonus/Kinsbourne Syndrome) to support medical necessity.
- Documentation of patient age for infantile spasms (patient is less than 2 years old).
Key Coverage Criteria
- Acthar Gel (repository corticotropin injection) and Purified Cortrophin Gel (repository corticotropin injection USP) are proven and medically necessary for the treatment of: Infantile spasm (i.e., West Syndrome) for up to 4 weeks when all of the following criteria are met: Diagnosis of infantile spasms (i.e., West Syndrome); and Patient is less than 2 years old; and Provider attestation that the caregiver is not able to be trained or is physically unable to administer the drug; and Provider must [...]
- Acthar Gel (repository corticotropin injection) and Purified Cortrophin Gel (repository corticotropin injection USP) are proven and medically necessary for the treatment of: Opsoclonus-myoclonus syndrome (i.e., Kinsbourne Syndrome) when both of the following criteria are met: Diagnosis of opsoclonus-myoclonus syndrome (i.e., Kinsbourne Syndrome); and Provider attestation that the caregiver is not able to be trained or is physically unable to administer the drug; provider must submit explanation; [...]
- For members/plans designated as 'non-medical necessity' plans: Acthar Gel and Purified Cortrophin Gel may be covered for the treatment of acute exacerbation of multiple sclerosis (MS) (per policy language: "For non-medical necessity plans, Acthar Gel and Purified Cortrophin Gel may be covered for the treatment of acute exacerbation of multiple sclerosis (MS).")
- Aetna considers repository corticotropin injection (Acthar Gel only) medically necessary for treatment of infantile spasms in members who are less than 2 years of age.
- Continuation of repository corticotropin injection (Acthar Gel only) therapy is medically necessary for infantile spasms when the member has shown substantial clinical benefit from therapy.
- HCPCS codes J0801 and J0802 covered if selection criteria are met (Injection, corticotropin (acthar gel), up to 40 units; Injection, corticotropin (ani), up to 40 units).
4 Active Policies
AETNA-CPB-0762 — Repository Corticotropin Injection (Acthar Gel and Purified Cortrophin Gel)
UHC-POL-repository-corticotropin-injection-hp-acthar-gel — Repository Corticotropin Injections
UMR-POL-UMR-repository-corticotropin-injection-hp-acthar-gel — Repository Corticotropin Injections
SUREST-POL-SUREST-repository-corticotropin-injection-hp-acthar-gel — Repository Corticotropin Injections
Related Codes
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