Does J1427 require prior authorization?

No, J1427 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for J1427?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Submission of medical records (e.g., chart notes, laboratory values) confirming the DMD diagnosis
Submission of medical records confirming the mutation of the DMD gene is amenable to exon 53 skipping
For the ambulatory baseline requirement: medical records documenting either 6MWT ≥ 300 meters while walking independently OR documentation that the patient is ambulatory without an assistive device plus NSAA > 17 or time to rise (TTR) < 7 seconds
If patient previously received gene therapy for DMD, submission of medical records (e.g., chart notes, laboratory values) documenting a clinically meaningful functional decline resulting from loss of muscle strength/motor ability (e.g., loss of a motor milestone) since receiving gene replacement therapy

Covered when hospital outpatient facility infusion services for specialty medications and IVIG/SCIG therapy are considered medically necessary and the member meets the specific clinical criteria described in the policy.
OR Patient has achieved a time to rise (TTR) of less than 7 seconds
Patient has not previously received gene therapy [e.g., Elevidys (delandistrogene moxparvovec-rokl)] for the treatment of DMD
OR if the patient has previously received gene therapy for DMD, both of the following must be met:
Patient has achieved a score of greater than 17 on the North Star Ambulatory Assessment (NSAA)
Viltepso (viltolarsen) may be covered for the treatment of Duchenne muscular dystrophy (DMD) in patients who meet all of the following criteria:

UHC-POL-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care

UMR-POL-UMR-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care

UMR-POL-UMR-viltepso, Viltepso (Viltolarsen)

UHC-POL-viltepso, Viltepso (Viltolarsen)

SUREST-POL-SUREST-viltepso, Viltepso (Viltolarsen)

Ask Verity about documentation requirements, denial risks, or coverage in your state.