J1437, Injection, ferric derisomaltose, 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
- For initial therapy, all of the following: o Submission of medical records (e.g., lab values, chart notes, etc.) supporting the diagnosis of IDA; and o Patient does not have CKD; and
- Submission of medical records (e.g., lab values, chart notes, etc.) supporting the diagnosis of IDA; and
- Submission of laboratory values demonstrating treatment failure to at least two of the following intravenous iron therapies (Note: Laboratory values should be obtained within 4 to 12 weeks following the last dose of intravenous iron in a treatment course.): Ferrlecit® (sodium ferric gluconate complex) Infed® (iron dextran) Venofer® (iron sucrose)
Key Coverage Criteria
- Feraheme and Injectafer are medically necessary when the following criteria are met: For initial therapy, all of the following: o Submission of medical records (e.g., lab values, chart notes, etc.) supporting the diagnosis of IDA; and o Patient does not have CKD; and o One of the following: History of failure, contraindication, or intolerance, to oral iron therapy; or Intravenous Iron Replacement Therapy (Feraheme®, Injectafer®, & Monoferric®) Page 1 of 11
- Feraheme (ferumoxytol), Injectafer (ferric carboxymaltose), and Monoferric (ferric derisomaltose) are proven for the following indications: Iron Deficiency Anemia (IDA) Without CKD Feraheme and Injectafer are medically necessary when the following criteria are met:
3 Active Policies
UHC-POL-iv-iron-replacement-therapy, Intravenous Iron Replacement Therapy (Feraheme, Injectafer, & Monoferric)
UMR-POL-UMR-iv-iron-replacement-therapy, Intravenous Iron Replacement Therapy (Feraheme, Injectafer, & Monoferric)
SUREST-POL-SUREST-iv-iron-replacement-therapy, Intravenous Iron Replacement Therapy (Feraheme, Injectafer, & Monoferric)
Related Codes
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