J9216, Injection, interferon, gamma 1-b, 3 million units
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Diagnosis documentation: 'Diagnosis is usually made after a detailed medical history has been taken, infectious or dermatological abnormalities has been ruled out, and pain is elicited in response to light pressure on the labia, introitus, or hymenal remnants.' (policy background text).
- Demonstration of pain localization/testing: cotton swab test (cotton-swab test) for differentiating localized vulvodynia/vestibulitis and to outline areas of pain (policy background describes use of cotton swab test).
- Evidence of failure of conservative measures prior to vestibulectomy: documentation that conservative measures were tried and failed, including vulvar care, physical therapy, pharmacotherapy (including analgesics) — required for vestibulectomy to be medically necessary per policy: 'Vestibulectomy (local or total) for persons who have failed conservative measures (including vulvar care, physical therapy, pharmacotherapy including analgesics).'
Key Coverage Criteria
- Members with vulvodynia/vulvar vestibulitis
- Physical therapy (medically necessary for members with vulvodynia/vulvar vestibulitis)
- Perineoplasty (medically necessary for members with vulvodynia/vulvar vestibulitis)
- Vestibulectomy (local or total) for persons who have failed conservative measures (including vulvar care, physical therapy, pharmacotherapy including analgesics).
- CPT codes covered if selection criteria are met: 56620-56640 (Vulvectomy range), 56810 (Perineoplasty, repair of perineum, nonobstetrical), 97010-97032, 97034-97039 (Physical medicine and rehabilitation modalities), 97110-97139 (Physical medicine and rehabilitation therapeutic procedures).
- ICD-10 codes covered if selection criteria are met: N94.810 - N94.819 (Vulvodynia [vulvodynia and vulvar vestibulitis])
8 Active Policies
AETNA-CPB-0759, Vulvodynia and Vulvar Vestibulitis Treatments
EVICORE-HPLAN-CIGNA-91DEEEDD92F8, Cigna MedOnc Master Drug List
EVICORE-HPLAN-CIGNA_MEDICARE-F57DF6FC9C3C, Q1 - 2025 1199 SEIU Benefit Funds MedOnc Master Drug List
EVICORE-HPLAN-CIGNA_MEDICARE-6408D93491D1, Q1 - 2026 1199 SEIU Benefit Funds MedOnc Master Drug List
Related Codes
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