J1301 — Injection, edaravone, 1 mg
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
- Submission of medical records (e.g., chart notes, previous medical history, diagnostic testing including imaging, nerve conduction studies, laboratory values) to support the diagnosis of ALS.
- Submission of the most recent ALS Functional Rating Scale-Revised (ALSFRS-R) score confirming that the patient has scores 63; 2 in all items of the ALSFRS-R criteria at the start of treatment.
- Submission of medical records (e.g., chart notes, laboratory values) confirming that the patient has a % forced vital capacity (%FVC) 63; 80% at the start of treatment.
- Provider attestation that the patient or caregiver is not competent or is physically unable to administer Radicava ORS oral suspension either orally or via feeding tube.
Key Coverage Criteria
- Submission of medical records (e.g., chart notes, laboratory values) confirming that the patient has a % forced vital capacity (%FVC) 63; 80 % at the start of treatment; and
- Edaravone dosing for ALS is in accordance with the United States Food and Drug Administration approved labeling; and
- Edaravone is proven and medically necessary for the treatment of amyotrophic lateral sclerosis (ALS) in patients who meet all of the following criteria:
- For initial therapy, all of the following:
- Submission of medical records (e.g., chart notes, previous medical history, diagnostic testing including imaging, nerve conduction studies, laboratory values) to support the diagnosis of ALS; and
- Submission of the most recent ALS Functional Rating Scale-Revised (ALSFRS-R) score confirming that the patient has scores 63; 2 in all items of the ALSFRS-R criteria at the start of treatment; and
14 Active Policies
UHC-POL-edaravone — Edaravone
UHC-POL-provider-administered-drugs-soc — Provider Administered Drugs – Site of Care
UMR-POL-UMR-edaravone — Edaravone
UMR-POL-UMR-provider-administered-drugs-soc — Provider Administered Drugs – Site of Care
SUREST-POL-SUREST-edaravone — Edaravone
Related Codes
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