J3240, Injection, thyrotropin alpha, 0.9 mg, provided in 1.1 mg vial
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
- For adjunctive use in non-toxic multinodular goiter: documentation that Thyrogen is being used as an adjunct to radioiodine ablation.
- When Tg testing is planned, documentation of anti-Tg antibody status should be available, given that anti-Tg antibodies may render Tg levels uninterpretable
- If HCPCS J3240 is billed: medical record evidence supporting that "selection criteria are met" (diagnosis and clinical rationale as above).
- Documentation of the covered diagnosis (e.g., malignant neoplasm of thyroid C73; nontoxic multinodular goiter E04.2; personal history of thyroid neoplasm Z85.850) as applicable.
Key Coverage Criteria
- HCPCS J3240 (Injection, thyrotropin alpha, 0.9 mg, provided in 1.1 mg vial) when selection criteria are met
- ICD-10 diagnoses covered if selection criteria are met: C73 (Malignant neoplasm of thyroid gland) [except for suppressed serum thyroglobulin (less than 0.1 ng/ml)], E04.2 (Nontoxic multinodular goiter) [adjunct to radioiodine ablation], Z85.850 (Personal history of malignant neoplasm of thyroid)
- For thyroglobulin (Tg) testing and radioiodine imaging in place of thyroid hormone withdrawal for any of the following groups with differentiated thyroid carcinoma:
- Members in whom withdrawal from hormone supplement is contraindicated for medical reasons;
- Members requiring serum Tg testing and radioiodine imaging who are unwilling to undergo thyroid hormone withdrawal testing and whose treating physician believes that use of a less sensitive test is justified;
- Members who are either unable to mount an adequate endogenous thyroid stimulating hormone (TSH) response to thyroid hormone withdrawal;
1 Active Policy
AETNA-CPB-0515, Thyrogen (Thyrotropin Alfa)
Related Codes
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