J2327, Injection, risankizumab-rzaa, intravenous, 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
- Clinical documentation demonstrating the therapy is effective for the relevant diagnosis or procedure.
- For drug therapy, documentation of the proposed dose, frequency, and duration and citation(s) to at least one authoritative source (e.g., FDA labeling, DrugDex, NCCN, MCG).
- Supporting references from peer-reviewed literature, nationally recognized compendia, or applicable clinical guidelines when applicable.
- Documentation of Crohn's Disease Activity Index (CDAI) showing score 220–450.
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.
- Indication for Crohn’s disease: diagnosis of moderately to severely active Crohn’s disease with three intravenous induction doses of risankizumab (600 mg or 1200 mg per induction as per FDA labeling for CD), not in combination with another targeted immunomodulator, with authorization for 3 induction doses.
- Therapies that are proven effective for the relevant diagnosis or procedure based on generally accepted clinical standards.
- Drug therapy when the proposed dose, frequency, and duration are consistent with recommendations in at least one authoritative source.
- Therapies and drug uses supported by FDA-approved labeling and/or nationally recognized authoritative references (examples: MCG, DrugDex level IIa+, NCCN Guidelines/Compendia).
- Adults meeting the policy criteria receive the first three doses of risankizumab (Skyrizi) as intravenous infusions at week 0, week 4, and week 8.
10 Active Policies
UHC-POL-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care
UHC-POL-skyrizi, Skyrizi (Risankizumab-Rzaa)
RX501.147, Risankizumab-rzaa
BCBSIL-RX501.147, Risankizumab-rzaa
BCBSMT-RX501.147, Risankizumab-rzaa
Related Codes
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