J2351, Injection, ocrelizumab, 1 mg and hyaluronidase-ocsq
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
- Documentation of the patient’s diagnosis and clinical rationale demonstrating the therapy’s effectiveness for that diagnosis.
- For drug therapy, documentation of the proposed dose, frequency, and duration of therapy.
- Citation or copy of at least one authoritative reference supporting the proposed therapy (e.g., FDA labeling, DrugDex entry, NCCN guideline/compendium, MCG guideline, or peer-reviewed literature).
- Providers and members must consult the member's benefit plan/summary plan description/contract to determine applicable coverage, exclusions, and limitations.
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.
- Therapy is covered when it is proven effective for the relevant diagnosis or procedure based on generally accepted standards of practice.
- Drug therapy is covered when the proposed dose, frequency, and duration are consistent with recommendations in at least one authoritative source (e.g., FDA labeling, DrugDex, NCCN, MCG).
- Coverage supported by FDA-approved labeling, nationally recognized compendia, or peer-reviewed scientific literature.
- Coverage of FDA‑approved drugs (e.g., ocrelizumab or ocrelizumab with hyaluronidase) when prescribed for a use recognized as safe and effective in one or more standard medical reference compendia adopted by HHS, even if the drug is not FDA‑approved for that specific indication.
- Coverage of an FDA‑approved drug for an off‑label use when safety and efficacy for that use are supported in the medical literature (see documentation requirements).
14 Active Policies
UHC-POL-ocrevus-ocrelizumab, Ocrevus (Ocrelizumab) and Ocrevus Zunovo (Ocrelizumab and Hyaluronidase-Ocsq)
UHC-POL-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care
RX501.085, Ocrelizumab or Ocrelizumab and Hyaluronidase-ocsq
BCBSIL-RX501.085, Ocrelizumab or Ocrelizumab and Hyaluronidase-ocsq
BCBSIL-ADM1001.034, Specialty Medication Administration Site of Care
Related Codes
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