J2507 — Injection, pegloticase, 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
- Submission of laboratory values demonstrating baseline serum uric acid level >6 mg/dL prior to initiation.
- Documentation of prior trials showing contraindication, intolerance, or treatment failure (failure to normalize sUA to <6 mg/dL) after 3 months of therapy at maximally medically appropriate dose with BOTH allopurinol and febuxostat (including dates, doses, and reason for discontinuation or failure).
- Prescriber attestation that serum uric acid levels will be monitored prior to each infusion and that treatment will be discontinued/considered for discontinuation if preinfusion sUA increases above 6 mg/dL.
- Ongoing monitoring records showing pre-infusion serum uric acid values for each infusion (for continuation/reauthorization assessments).
Key Coverage Criteria
- Symptomatic gout with at least 1 gouty tophus.
- Chronic gouty arthropathy.
- Treatment of chronic gout refractory to conventional therapy in adult patients (per FDA indication).
- Symptomatic gout with history of at least 2 gout flares in the previous 12 months (meets the policy definition of symptomatic gout).
- Initial therapy when there is history of contraindication, intolerance, or treatment failure (failure to normalize serum uric acid to <6 mg/dL) after 3 months of therapy at the maximally medically appropriate dose with BOTH allopurinol AND febuxostat.
- Continuation (reauthorization) of Krystexxa for patients who previously received Krystexxa and have experienced a positive clinical response (e.g., serum uric acid <6 mg/dL, tophus reduction) and have not had two consecutive uric acid levels >6 mg/dL after initiating treatment.
12 Active Policies
UHC-POL-krystexxa-pegloticase — Krystexxa (Pegloticase)
UMR-POL-UMR-krystexxa-pegloticase — Krystexxa (Pegloticase)
SUREST-POL-SUREST-krystexxa-pegloticase — Krystexxa (Pegloticase)
BCBSIL-RX501.120 — Pegloticase
BCBSMT-RX501.120 — Pegloticase
Related Codes
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