J1426 — Injection, casimersen, 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
- Submission of medical records (e.g., chart notes, laboratory values) confirming the mutation of the DMD gene is amenable to exon 45 skipping.
- Medical record documentation that the patient has a 6-Minute Walk Test (6MWT) 60 300 meters while walking independently (e.g., without side-by-side assist, cane, walker, wheelchair, etc.) prior to beginning Amondys 45 therapy.
- If 6MWT criterion is not used, submission of medical records (e.g., chart notes) confirming that the patient is ambulatory without needing an assistive device (e.g., without side-by-side assist, cane, walker, wheelchair, etc.).
- Submission of medical records showing the North Star Ambulatory Assessment (NSAA) score (patient must have achieved a score of greater than 17 if using the NSAA pathway).
Key Coverage Criteria
- Dosing is in accordance with the United States Food and Drug Administration approved labeling
- Initial authorization will be for no more than 12 months
- Amondys 45 (casimersen) may be covered 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 neurologist with expertise in the diagnosis of DMD;
- Submission of medical records (e.g., chart notes, laboratory values) confirming the mutation of the DMD gene is amenable to exon 45 skipping;
- Patient has a 6-Minute Walk Test (6MWT) 60 300 meters while walking independently (e.g., without side-by-side assist, cane, walker, wheelchair, etc.) prior to beginning Amondys 45 therapy;
5 Active Policies
UHC-POL-amondys — Amondys 45 (Casimersen)
UHC-POL-provider-administered-drugs-soc — Provider Administered Drugs – Site of Care
UMR-POL-UMR-amondys — Amondys 45 (Casimersen)
UMR-POL-UMR-provider-administered-drugs-soc — Provider Administered Drugs – Site of Care
SUREST-POL-SUREST-amondys — Amondys 45 (Casimersen)
Related Codes
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