J1302 — Injection, sutimlimab-jome, 10 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
- Immunoglobulin G (IgG) DAT ≤ 1+ (document lab result)
- Cold agglutinin titer ≥ 64 at 4°C (document lab result)
- Diagnosis of CAD by, or in consultation with, a hematologist with expertise in the diagnosis of CAD (document consultation or treating hematologist)
- Documentation confirming CAD diagnosis including evidence of chronic hemolysis (e.g., elevated LDH, decreased haptoglobin, increased indirect bilirubin, increased reticulocyte count)
Key Coverage Criteria
- Enjaymo is proven for the treatment of cold agglutinin disease (CAD).
- Medically necessary for the treatment of CAD in patients who meet ALL of the following criteria (Initial therapy):
- Diagnosis of CAD by, or in consultation with, a hematologist with expertise in the diagnosis of CAD
- Confirmation of the CAD diagnosis based on all of the following: Evidence of chronic hemolysis [e.g., elevated lactated dehydrogenase (LDH), decreased haptoglobin, increased indirect bilirubin, increased reticulocyte count]
- Confirmation of the CAD diagnosis based on all of the following: Positive polyspecific direct antiglobin test (DAT)
- Confirmation of the CAD diagnosis based on all of the following: Positive monospecific DAT specific for C3d
18 Active Policies
UHC-POL-enjaymo — Enjaymo (Sutimlimab-Jome)
UHC-POL-provider-administered-drugs-soc — Provider Administered Drugs – Site of Care
UMR-POL-UMR-enjaymo — Enjaymo (Sutimlimab-Jome)
UMR-POL-UMR-provider-administered-drugs-soc — Provider Administered Drugs – Site of Care
SUREST-POL-SUREST-enjaymo — Enjaymo (Sutimlimab-Jome)
Related Codes
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