J7171 — Injection, adamts13, recombinant-krhn, 10 iu
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
- Patient age documentation to confirm adult status (≥ 18 years)
- Reference to the member specific benefit plan document is required when deciding coverage.
- Check applicable federal or state mandates prior to applying this policy.
- Confirmation of ADAMTS13 mutation by molecular genetic testing.
Key Coverage Criteria
- Adzynma (ADAMTS13, recombinant-krhn) is proven and medically necessary for prophylactic treatment of congenital thrombotic thrombocytopenic purpura (cTTP) in patients who meet all of the following criteria:
- For initial therapy: Diagnosis of congenital thrombotic thrombocytopenic purpura (cTTP) where Adzynma is being prescribed for routine prophylactic treatment to prevent thrombotic thrombocytopenic purpura (TTP) events, with ADAMTS13 mutation confirmed by molecular genetic testing.
- For continuation of therapy: Patient previously received routine prophylactic treatment with Adzynma and Adzynma is being continued for ongoing routine prophylactic treatment to prevent TTP events, with documentation of positive clinical response to Adzynma therapy.
- Adzynma (ADAMTS13, recombinant-krhn) is proven and medically necessary for on demand treatment of an acute thrombotic thrombocytopenic purpura (TTP) event in patients with congenital thrombotic thrombocytopenic purpura (cTTP) who meet all of the following criteria:
- Diagnosis of congenital thrombotic thrombocytopenic purpura (cTTP)
- ADAMTS13 mutation is confirmed by molecular genetic testing
5 Active Policies
UHC-POL-adzynma — Adzynma (ADAMTS13, Recombinant-Krhn)
UHC-POL-provider-administered-drugs-soc — Provider Administered Drugs – Site of Care
UMR-POL-UMR-adzynma — Adzynma (ADAMTS13, Recombinant-Krhn)
UMR-POL-UMR-provider-administered-drugs-soc — Provider Administered Drugs – Site of Care
SUREST-POL-SUREST-adzynma — Adzynma (ADAMTS13, Recombinant-Krhn)
Related Codes
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