M0224, Intravenous infusion, pemivibart, for the pre-exposure prophylaxis only, for
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
- Clinical documentation of the relevant diagnosis or procedure supporting the request.
- For drug therapy, documentation of the proposed dose, frequency, and duration.
- Citation or documentation of the authoritative source(s) supporting effectiveness and the recommended dosing/frequency/duration (e.g., FDA labeling, MCG, DrugDex, NCCN, peer‑reviewed literature).
- Record of patient age (≥12 years) and weight (≥40 kg).
Key Coverage Criteria
- Therapies must be proven effective for the relevant diagnosis or procedure to be considered for coverage.
- Drug therapies are covered when the proposed dose, frequency, and duration are consistent with recommendations in at least one authoritative source (e.g., FDA-approved labeling, MCG, DrugDex, NCCN).
- Pre-exposure prophylaxis of COVID-19 in adults and adolescents (≥12 years of age) weighing at least 40 kg.
- Patient is not currently infected with SARS‑CoV‑2 and has no known recent exposure to an individual infected with SARS‑CoV‑2.
- Patient has moderate to severe immune compromise from a medical condition or receipt of immunosuppressive medications/treatments and is unlikely to mount an adequate immune response to COVID-19 vaccination.
- Use limited to circumstances authorized by the FDA Emergency Use Authorization (EUA) issued March 22, 2024; follow EUA-specified indications.
1 Active Policy
RX501.173, Pemivibart
Related Codes
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