J1324, Injection, enfuvirtide, 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
- "The member has viremia despite 3 or more prior months of therapy with at least one appropriate regimen used to treat HIV;" — documentation of viremia and prior therapies (>= 3 months) required.
- "The member has viremia and documented resistance or intolerance to at least one appropriate regimen used to treat HIV." — documentation of viremia and laboratory or clinical evidence of resistance or intolerance required.
- For continuation: documentation that "the member has had a positive or stable virologic response to enfuviritide."
- Use of ICD-10 code B20 (Human immunodeficiency virus [HIV] disease) when selection criteria are met.
Key Coverage Criteria
- Aetna considers enfuvirtide (Fuzeon) injection medically necessary for the treatment of human immunodeficiency virus type 1 (HIV-1) infection when either of the following criteria is met:
- The member has viremia despite 3 or more prior months of therapy with at least one appropriate regimen used to treat HIV;
- The member has viremia and documented resistance or intolerance to at least one appropriate regimen used to treat HIV.
- Aetna considers continuation of enfuvirtide (Fuzeon) therapy medically necessary for treatment of HIV-1 infection when the member has had a positive or stable virologic response to enfuviritide.
- HCPCS code J1324 (Injection, enfuvirtide, 1 mg) covered if selection criteria are met.
- ICD-10 code B20 (Human immunodeficiency virus [HIV] disease) covered if selection criteria are met.
1 Active Policy
AETNA-CPB-0671, Enfuvirtide (Fuzeon)
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