J1413 — Injection, delandistrogene moxeparvovec-rokl, per therapeutic dose
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, laboratory values) confirming a mutation in the DMD gene
- Submission of medical records confirming the mutation is not a deletion in exon 8 or exon 9
- Submission of medical records (e.g., chart notes) confirming that the patient is ambulatory without needing an assistive device
- Documentation of patient age showing the patient is 4 or 5 years of age
Key Coverage Criteria
- Patient does not have an elevated anti-AAVrh74 total binding antibody titer ≥ 1:400
- Elevidys is proven and medically necessary for the treatment of Duchenne muscular dystrophy (DMD) in patients who meet all of the following criteria:
- Diagnosis of Duchenne muscular dystrophy by, or in consultation with, a pediatric neuromuscular specialist with expertise in the diagnosis of DMD
- Submission of medical records confirming a mutation in the DMD gene
- Submission of medical records confirming the mutation is not a deletion in exon 8 or exon 9
- Patient is aged 4 or 5 years of age
4 Active Policies
UHC-POL-elevidys — Elevidys (Delandistrogene Moxeparvovec-Rokl)
ANTHEM-MED.00144 — MED.00144 Gene Therapy for Duchenne Muscular Dystrophy
UMR-POL-UMR-elevidys — Elevidys (Delandistrogene Moxeparvovec-Rokl)
SUREST-POL-SUREST-elevidys — Elevidys (Delandistrogene Moxeparvovec-Rokl)
Related Codes
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