J1300, Injection, eculizumab, 10 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Clinical documentation supporting the diagnosis of Guillain-Barre syndrome (ICD-10 G61.0) and relevant clinical findings (onset, severity, ambulatory status, respiratory compromise, etc.) to justify use of IVIG or plasmapheresis per the referenced CPBs.
- Medical records to support medical necessity for procedures/therapies billed with CPT/HCPCS codes listed as covered (e.g., 36514, 90283, J1561/J1566/J1568/J1569, S9473) including notes, test results, and treatment course consistent with the applicable CPB selection criteria.
- Documentation that selection/medical necessity criteria in the referenced CPBs are met: CPB 0206 - Parenteral Immunoglobulins (for IVIG), CPB 0285 - Plasmapheresis/Plasma Exchange/Therapeutic Apheresis (for plasmapheresis), and CPB 0032 - Pulmonary Rehabilitation (for outpatient pulmonary rehab).
Key Coverage Criteria
- Outpatient pulmonary rehabilitation program for patients with Guillain-Barre syndrome when criteria listed in CPB 0032 - Pulmonary Rehabilitation are met.
- CPT/HCPCS codes covered if selection criteria are met: 36514 (Therapeutic apheresis; for plasma pheresis) and 90283 (Immune globulin (IgIV), human, for intravenous use).
- Guillain-Barre syndrome (ICD-10: G61.0) — treatment of GBS
- Intravenous immunoglobulin (IVIG) for the treatment of Guillain-Barre syndrome when criteria in CPB 0206 - Parenteral Immunoglobulins are met.
- Plasmapheresis (therapeutic apheresis / plasma exchange) for the treatment of Guillain-Barre syndrome when criteria in CPB 0285 - Plasmapheresis/Plasma Exchange/Therapeutic Apheresis are met.
- HCPCS codes covered if selection criteria are met: J1561, J1566, J1568, J1569 (immune globulin products) and S9473 (Pulmonary rehabilitation program, non-physician provider, per diem).
2 Active Policies
AETNA-CPB-0732, Guillain-Barre Syndrome Treatments
RX501.066, Eculizumab and Associated Biosimilar(s)
Related Codes
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