J2315 — Injection, naltrexone, depot form, 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
- No specific clinical documentation requirements (e.g., required test results or notes) are listed in this policy for compounded naltrexone pellets.
- When deciding coverage, the member specific benefit plan document must be referenced as the terms of the member specific benefit plan may differ from the standard plan; in the event of a conflict, the member specific benefit plan document governs.
- Before using this policy, check the member specific benefit plan document and any applicable federal or state mandates.
- For some systemic or investigational therapy trials, baseline and end-of-study laboratory tests were obtained: "Blood samples for measurements of complete blood count along with thyroid function (T3, T4 and TSH) and liver function tests were taken at the baseline and at the end of study." (triiodothyronine trial)
Key Coverage Criteria
- None. "Compounded drugs, including compounded naltrexone pellets, are not FDA approved."
- "Compounded drug pellets, including but not limited to compounded naltrexone, are not proven nor medically necessary for any indication."
- This policy does not apply to Vivitrol® (naltrexone powder for suspension for injection, extended-release).
- Extensive alopecia areata (involving more than 50 % loss of scalp hair) — treatments may include topical immunotherapy, systemic agents or other measures: "Therapy for extensive alopecia areata (involving more than 50 % loss of scalp hair) may be prolonged and difficult...Systemic corticosteroids are seldom used due to their adverse effects; however, they may be required depending on the severity of the condition and the adequacy of the response to topical therapy."
- Topical immunotherapy (DPCP/DCP and SADBE) for scalp hair loss of 50 to 99 % — "Topical immunotherapy...with reported hair growth rates of 40 to 60 % among patients with scalp hair loss of 50 to 99 %."
- Psoralen photochemotherapy (PUVA) as an option for alopecia areata (used in practice by AAD despite limited evidence) — "Psoralen photochemotherapy (psoralen and ultraviolet light A or PUVA) is another immunosuppressant treatment that is used for alopecia areata...Despite these limitations, PUVA is still considered standard practice of care by the American Academy of Dermatology."
2 Active Policies
AETNA-CPB-0423 — Alopecia Areata
UHC-POL-subcutaneous-implant-naltrexone-pellets — Subcutaneous Implantable Naltrexone Pellets
Related Codes
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