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
- Precertification of repository corticotropin injection (Acthar Gel or Purified Cortrophin Gel) is required. For precertification of Acthar Gel or Purified Cortrophin Gel, call (866) 752-7021 or fax (888) 267-3277. For Statement of Medical Necessity (SMN) precertification forms, see Specialty Pharmacy Precertification.
- Documentation that the patient is less than 2 years of age and has the diagnosis of infantile spasms (Epileptic spasms [West's syndrome]; ICD-10: G40.821 - G40.824) when requesting coverage for Acthar Gel.
- If Purified Cortrophin Gel is being considered for other uses, the policy notes the manufacturer labeling recommendation that 'Standard tests for verification of adrenal responsiveness to corticotropin... Verification tests should be performed prior to treatment with corticotropins' — however Aetna considers corticotropin not medically necessary for diagnostic testing of adrenocortical function.
Key Coverage Criteria
- Acthar Gel (repository corticotropin injection) and Purified Cortrophin Gel (repository corticotropin injection USP) are medically necessary for infantile spasms (West Syndrome) up to 4 weeks if: diagnosis of infantile spasms, patient <2 years, caregiver training/ability issue with explanation, dosing per FDA labeling, authorization up to 1 month; and for opsoclonus-myoclonus syndrome with diagnosis and caregiver training/ability issue with explanation, authorization up to 3 months.
- 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).
- ICD-10 codes covered if selection criteria are met: G40.821 - G40.824 (Epileptic spasms [West's syndrome]) — [Acthar gel only].
- Recommended dosage regimen for the treatment of acute exacerbations in adults with multiple sclerosis: The recommended dose is daily intramuscular or subcutaneous doses of 80-120 units for 2 to 3 weeks for acute exacerbations.
4 Active Policies
UHC-POL-repository-corticotropin-injection-hp-acthar-gel, Repository Corticotropin Injections
AETNA-CPB-0762, Repository Corticotropin Injection (Acthar Gel and Purified Cortrophin Gel)
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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