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 diagnosis: PPMS or relapsing forms of multiple sclerosis (e.g., relapsing-remitting MS, secondary-progressive MS with relapses, progressive-relapsing MS with relapses) — medical records supporting diagnosis.
- For initial authorization: documentation that the patient is not receiving Ocrevus/Ocrevus Zunovo in combination with the listed disease modifying therapies, B-cell targeted therapies, or lymphocyte trafficking blockers.
- For continuation of therapy: documentation that the patient has previously received Ocrevus or Ocrevus Zunovo and documentation of positive clinical response to Ocrevus or Ocrevus Zunovo therapy.
- Documentation that Ocrevus or Ocrevus Zunovo dosing is in accordance with the FDA approved labeling (dose and schedule).
Key Coverage Criteria
- Primary progressive multiple sclerosis (PPMS) — Ocrevus and Ocrevus Zunovo are medically necessary for the treatment of primary progressive multiple sclerosis (PPMS) when all of the following criteria are met: For initial therapy: Diagnosis of primary progressive multiple sclerosis (PPMS); Patient is not receiving Ocrevus or Ocrevus Zunovo in combination with any of the following: Disease modifying therapy (e.g., interferon beta preparations, dimethyl fumarate, glatiramer acetate, natalizumab, f [...]
- Primary progressive multiple sclerosis (PPMS) — continuation of therapy: Patient has previously received treatment with Ocrevus or Ocrevus Zunovo; Documentation of positive clinical response to Ocrevus or Ocrevus Zunovo therapy; Patient is not receiving Ocrevus or Ocrevus Zunovo in combination with any of the following: Disease modifying therapy (e.g., interferon beta preparations, dimethyl fumarate, glatiramer acetate, natalizumab, fingolimod, cladribine, siponimod, or teriflunomide); B cell ta [...]
- Relapsing forms of multiple sclerosis (MS) — Ocrevus and Ocrevus Zunovo are medically necessary for the treatment of relapsing forms of multiple sclerosis (MS) (e.g., relapsing-remitting MS, secondary-progressive MS with relapses, progressive-relapsing MS with relapses) when all of the following criteria are met: For initial therapy: Diagnosis of relapsing forms of multiple sclerosis (MS); Patient is not receiving Ocrevus or Ocrevus Zunovo in combination with any of the following: Disease modify [...]
- Relapsing forms of multiple sclerosis (MS) — continuation of therapy: Patient has previously received treatment with Ocrevus or Ocrevus Zunovo; Documentation of positive clinical response to Ocrevus or Ocrevus Zunovo therapy; Patient is not receiving Ocrevus or Ocrevus Zunovo in combination with any of the following: Disease modifying therapy (e.g., interferon beta preparations, dimethyl fumarate, glatiramer acetate, natalizumab, fingolimod, cladribine, siponimod, or teriflunomide); B cell targe [...]
- FDA-indicated population (informational): "treatment of adult patients with relapsing forms of multiple sclerosis (including clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease), or primary progressive multiple sclerosis."
- Authorization of hospital outpatient facility infusion services (place of service codes 19 and 22) for specialty medications and IVIG/SCIG when outpatient hospital facility-based administration is medically necessary and the member meets at least one of the criteria below.
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
UMR-POL-UMR-ocrevus-ocrelizumab — Ocrevus (Ocrelizumab) and Ocrevus Zunovo (Ocrelizumab and Hyaluronidase-Ocsq)
UMR-POL-UMR-provider-administered-drugs-soc — Provider Administered Drugs – Site of Care
Related Codes
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