J3241, Injection, teprotumumab-trbw, 10 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
- Evidence that the requested therapy is effective for the relevant diagnosis or procedure (clinical evidence or authoritative references).
- For drug therapy, documentation of proposed dose, frequency, and duration plus citation to at least one authoritative source (FDA labeling, DrugDex, NCCN, MCG, peer-reviewed literature).
- If relying on compendia: citation(s) to the standard medical reference compendium entry recognizing the off‑label use.
- If relying on literature: two articles from major peer‑reviewed professional medical journals presenting data supporting the proposed off‑label use and demonstrating safety and efficacy.
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.
- Tepezza is medically necessary for a diagnosis of thyroid eye disease (TED) with moderately to severe disease, evidenced by either (i) symptomatic, active disease plus one of: lid retraction ≥ 2 mm or moderate/severe soft tissue involvement or proptosis ≥ 3 mm above normal for race/sex, or (ii) stable, chronic inactive disease plus one of: proptosis ≥ 3 mm from before TED or proptosis ≥ 3 mm above normal values for race/sex, and one of: presence of significant proptosis or diplopia; or absence o [...]
- Therapies are covered only when proven effective for the relevant diagnosis or procedure.
- 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 of any FDA‑approved drug when prescribed for a use recognized as safe and effective in one or more standard medical reference compendia adopted by the U.S. Department of Health and Human Services.
- Coverage of any FDA‑approved drug when prescribed for an off‑label use supported by at least two articles from major peer‑reviewed professional medical journals that demonstrate safety and efficacy.
14 Active Policies
UHC-POL-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care
UHC-POL-tepezza, Tepezza (Teprotumumab-Trbw)
BCBSIL-ADM1001.034, Specialty Medication Administration Site of Care
BCBSIL-RX501.110, Teprotumumab-trbw
BCBSMT-ADM1001.034, Specialty Medication Administration Site of Care
Related Codes
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