S0088, Imatinib, 100 mg
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
- When billing, use HCPCS/CPT/ICD-10 codes listed in the policy and ensure selection criteria and supporting documentation are present (policy lists covered and not-covered codes).
- Administrative contact information for precertification provided in policy (Commercial call: (866) 752-7021; fax: (888) 267-3277) — documentation of precertification/authorization as applicable.
- Hospital admission and documented pulmonary vasodilator responsiveness testing (incremental doses of a short-acting pulmonary vasodilator administered intravenously during right heart catheterization) to determine selection of vasodilator treatment.
- Hemodynamic documentation of a 'positive response' during vasodilator testing: a decrease of 20% or more in pulmonary vascular resistance and pulmonary arterial pressure with no decrease in cardiac output (explicit definition provided).
Key Coverage Criteria
- HCPCS/CPT/ICD-10 covered codes when selection criteria are met (examples listed in policy): J1325 (Injection, epoprostenol, 0.5 mg); J3285 (Injection, treprostinil, 1 mg); J7686 (Treprostinil, inhalation solution..., unit dose form, 1.74 mg); Q4074 (Iloprost, inhalation solution..., up to 20 micrograms); CPT 33741 (Transcatheter atrial septostomy); CPT 92997-92998 (Percutaneous transluminal pulmonary artery balloon angioplasty); ICD-10: I27.0; I27.20-I27.29; I27.83; I73.00-I73.01; J84.111-J84.11 [...]
- Treatment of pulmonary arterial hypertension (PAH; World Health Organization [WHO] Group 1) with epoprostenol/Flolan/Veletri to improve exercise capacity (studies predominately included patients with NYHA Functional Class III-IV and etiologies of idiopathic or heritable PAH or PAH associated with connective tissue diseases).
- Continuous intravenous epoprostenol or treprostinil for patients with pulmonary hypertension (including responders and non-responders to conventional therapy) to improve exercise tolerance, hemodynamics, symptoms and survival time.
- Treatment of PAH (WHO Group 1) with inhaled iloprost (Ventavis) to improve a composite endpoint consisting of exercise tolerance, symptoms (NYHA Class) and lack of deterioration (studies predominately included NYHA Class III-IV).
- Treatment of PAH (WHO Group 1) with treprostinil injection (Remodulin) to diminish symptoms associated with exercise (studies included NYHA Class II-IV and etiologies including idiopathic/heritable PAH, congenital shunts, connective tissue disease-associated PAH).
- Transition use: treprostinil (Remodulin) indicated to diminish rate of clinical deterioration in patients requiring transition from epoprostenol (i.e., patients transitioning from IV epoprostenol to treprostinil where risks/benefits considered).
8 Active Policies
AETNA-CPB-0184, Pulmonary Hypertension Treatments and Selected Indications of Prostanoids
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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