J0802, Injection, corticotropin (ani), 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
- Provider attestation that the caregiver is not able to be trained or is physically unable to administer the drug; provider must submit explanation; and
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.
- Indication: Acthar Gel and Purified Cortrophin Gel are medically necessary for infantile spasms (West Syndrome) up to 4 weeks when diagnosed as infantile spasms in a patient <2 years, caregiver cannot be trained or is unable to administer, dosing per FDA labeling, authorization up to 1 month; and for opsoclonus-myoclonus syndrome when diagnosed, caregiver cannot be trained or is unable to administer, authorization up to 3 months.
- 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: o Diagnosis of infantile spasms (i.e., West Syndrome); and o Patient is less than 2 years old; and o Provider attestation that the caregiver is not able to be trained or is physically unable to administer the d [...]
- Acthar Gel and Purified Cortrophin Gel are unproven and not medically necessary for treatment of the following disorders and diseases: Allergic States: Serum sickness and atopic dermatitis Collagen Diseases: Systemic lupus erythematosus and systemic dermatomyositis (polymyositis) Dermatologic Diseases: Severe erythema multiforme, Stevens-Johnson syndrome, and severe psoriasis Edematous State: To induce a diuresis or a remission of proteinuria in the nephrotic syndrome without ure [...]
- In a prospective, randomized, single-blinded study, Baram et al compared the efficacy of corticotropin (ACTH) and prednisone in suppressing clinical spasms and hypsarrhythmic electroencephalogram (EEG) in infantile spasms. Patients were randomized to receive either a 2-week course of treatment with repository corticotropin injection (75 U/m2 intramuscular twice daily) or prednisone (1 mg/kg by mouth twice daily). [...]
- Pranzatelli et al measured cerebrospinal fluid (CSF) ACTH and cortisol in 69 children with OMS and 25 age- and sex matched control subjects to determine endogenous levels and to look for hypothesized differential hormonal effects of ACTH and corticosteroid treatment. To compare high-dose versus low-dose, the ACTH-treated group was divided at the median (32 IU/m2/day) and the steroid group was also divided at the median (1.5 mg/kg/day). [...]
3 Active Policies
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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