Does Q0224 require prior authorization?

No, Q0224 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for Q0224?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

Verity

`Q0224` — Injection, pemivibart, for the pre-exposure prophylaxis only, for certain adults and adolescents (12 years of age and older weighing at least 40 kg) with no known sars-cov-2 exposure, and who either have moderate-to-severe immune compromise due to a medical condition or receipt of immunosuppressive medications or treatments, and are unlikely to mount an adequate immune response to covid-19 vaccination, 4500 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

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).

Documentation that the patient is not currently infected with SARS‑CoV‑2 and has no known recent exposure.

Clinical documentation of moderate to severe immunocompromise or use of immunosuppressive medications/treatments and why the patient is unlikely to mount an adequate immune response to COVID-19 vaccination.

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.

5 Active Policies

BCBSIL-RX501.173 — Pemivibart

BCBSMT-RX501.173 — Pemivibart

BCBSNM-RX501.173 — Pemivibart

BCBSOK-RX501.173 — Pemivibart

RX501.173 — Pemivibart

Related Codes

M0224(5 policies)

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