J1562, Injection, immune globulin (vivaglobin), 100 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Coverage determinations must include review of the member's benefit contract or SPD for coverage definitions, exclusions, and limitations (e.g., dollar or duration caps).
Key Coverage Criteria
- This policy addresses only the determination of medical necessity for the hospital outpatient setting for infusion and injectable therapy; the medical necessity of the pharmacologic or biologic medication itself may be reviewed separately.
- Requests for select medications intended for administration in a hospital outpatient setting will be directed to a preferred alternative site of care (non-hospital affiliated outpatient facility or home).
- This policy addresses only the determination of medical necessity for the hospital outpatient setting for infusion and injectable therapy; the medical necessity of the pharmacologic or biologic medication itself may be reviewed separately.
- Requests for select medications intended for administration in a hospital outpatient setting will be directed to a preferred alternative site of care (non-hospital affiliated outpatient facility or home).
- This policy addresses only the determination of medical necessity for the hospital outpatient setting for infusion and injectable therapy; the medical necessity of the pharmacologic or biologic medication itself may be reviewed separately.
- Requests for select medications intended for administration in a hospital outpatient setting will be directed to a preferred alternative site of care (non-hospital affiliated outpatient facility or home).
8 Active Policies
BCBSIL-RX504.003, Immunoglobulin Therapy
BCBSIL-ADM1001.034, Specialty Medication Administration Site of Care
BCBSMT-RX504.003, Immunoglobulin Therapy
BCBSMT-ADM1001.034, Specialty Medication Administration Site of Care
BCBSNM-RX504.003, Immunoglobulin Therapy
Related Codes
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