J1823, Injection, inebilizumab-cdon, 1 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 NMOSD: documentation of diagnosis by a neurologist confirming the listed past medical history features (optic neuritis; acute myelitis; area postrema syndrome; acute brainstem syndrome; symptomatic narcolepsy/acute diencephalic syndrome with NMOSD-typical MRI lesions; symptomatic cerebral syndrome with NMOSD-typical brain lesions) and that multiple sclerosis or other diagnoses have been ruled out.
- For NMOSD: positive serologic test result for anti-aquaporin-4 immunoglobulin G (AQP4-IgG)/NMO-IgG antibodies.
- For NMOSD: documentation of prior therapy status — either history of failure of rituximab; or history of intolerance/contraindication to rituximab plus physician attestation that same intolerance/severe adverse event would not be expected with Uplizna.
- For NMOSD: documentation of relapse history meeting policy (one or more relapses requiring rescue therapy in prior 12 months, or two or more relapses requiring rescue therapy in prior 24 months).
Key Coverage Criteria
- 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.
- Treatment of neuromyelitis optica spectrum disorder (NMOSD) in adult patients when all policy criteria are met.
- For NMOSD initial therapy — Diagnosis of neuromyelitis optica spectrum disorder (NMOSD) by a neurologist confirming: past medical history of one of the following: optic neuritis; acute myelitis; area postrema syndrome (episode of otherwise unexplained hiccups or nausea and vomiting); acute brainstem syndrome; symptomatic narcolepsy or acute diencephalic clinical syndrome with NMOSD-typical diencephalic MRI lesions; symptomatic cerebral syndrome with NMOSD-typical brain lesions; and positive sero [...]
- NMOSD additional initial-therapy requirements — one of the following: history of failure of rituximab therapy; or both history of intolerance or contraindication to rituximab and physician attests that, in their clinical opinion, the same intolerance or severe adverse event would not be expected to occur with Uplizna.
- NMOSD relapse history requirement — one of the following: history of one or more relapses that required rescue therapy during the previous 12 months prior to initiating Uplizna; or history of two or more relapses that required rescue therapy during the previous 24 months prior to initiating Uplizna.
- NMOSD prescribing/administration requirements — Uplizna is initiated according to the U.S. FDA labeled dosing for NMOSD; prescribed by, or in consultation with, a neurologist.
14 Active Policies
UHC-POL-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care
UHC-POL-uplizna, Uplizna (Inebilizumab-Cdon)
RX501.127, Inebilizumab-cdon
BCBSIL-RX501.127, Inebilizumab-cdon
BCBSIL-ADM1001.034, Specialty Medication Administration Site of Care
Related Codes
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