J0879 — Injection, difelikefalin, 0.1 microgram, (for esrd on dialysis)
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
- Documentation that pruritus is not limited to occurring only during the dialysis session and is not localized only to the palms.
- Documentation of a diagnosis of moderate-to-severe pruritus associated with chronic kidney disease.
- Documentation that the patient is receiving hemodialysis.
- For initial approval when using the 'medically necessary' criteria: documentation that pruritus is not attributed to other causes (e.g., pruritic dermatologic disease, cholestatic liver disease).
Key Coverage Criteria
- Treatment of moderate-to-severe pruritus associated with chronic kidney disease (CKD-associated pruritus, CKD-aP) in adults undergoing hemodialysis when policy criteria are met.
- FDA indication: Korsuva is indicated for the treatment of moderate-to-severe pruritus associated with chronic kidney disease in adults undergoing hemodialysis (informational).
3 Active Policies
UHC-POL-korsuva — Korsuva (Difelikefalin)
UMR-POL-UMR-korsuva — Korsuva (Difelikefalin)
SUREST-POL-SUREST-korsuva — Korsuva (Difelikefalin)
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