J3391, Injection, atidarsagene autotemcel, per treatment
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
Key Coverage Criteria
- A one-time infusion of atidarsagene autotemcel is consideredmedically necessaryin individuals who meetallof the following criteria:
- Diagnosis of metachromatic leukodystrophy (MLD); and
- Documentation of an arylsulfatase A (ARSA) genotype (biallelic ARSA pathogenic variant);and
- One of the following forms of MLD:Pre-symptomatic1late infantile MLD (children with expected disease onset at or before 30 months of age);orPre-symptomatic1early juvenile MLD (children with expected disease onset at more than 30 months and less than 7 years of age);orEarly symptomatic2early juvenile MLD (children with disease onset at more than 30 months of age and less than 7 years of age);and
- Pre-symptomatic1late infantile MLD (children with expected disease onset at or before 30 months of age);or
- Pre-symptomatic1early juvenile MLD (children with expected disease onset at more than 30 months and less than 7 years of age);or
1 Active Policy
ANTHEM-MED.00148, MED.00148 Gene Therapy for Metachromatic Leukodystrophy
Related Codes
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