Does S9346 require prior authorization?

No, S9346 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for S9346?

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

Verity

`S9346` — Home infusion therapy, alpha-1-proteinase inhibitor (e.g., prolastin); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem

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

Documented pretreatment serum AAT level < 11 micromol/L (80 mg/dL by radial immunodiffusion or 50 mg/dL by nephelometry).
Documented pretreatment post-bronchodilation FEV1 value ≥ 25% and ≤ 80% of predicted (forced expiratory volume in 1 second, post-bronchodilation).

Documented AAT genotype/phenotype: PiZZ, PiZ (null), or Pi (null, null) (homozygous) AAT deficiency or other phenotype/genotype associated with serum AAT < 11 micromol/L.

Documentation that the member does not have the PiMZ or PiMS AAT deficiency.

For Aralast NP, Glassia, or Zemaira requests, documentation of contraindication, intolerance, or an ineffective trial to Prolastin-C (per brand selection requirement).

Documentation of beneficial clinical response to support continuation of therapy.

Key Coverage Criteria

Aetna considers alpha 1-proteinase inhibitor (e.g., Aralast NP, Glassia, Prolastin-C, and Zemaira) therapy medically necessary for the treatment of emphysema due to alpha 1-antitrypsin (AAT) deficiency when all of the following criteria are met:
The member’s pretreatment serum AAT level is less than 11 micromol/L (80 mg/dL by radial immunodiffusion or 50 mg/dL by nephelometry);
The member’s pretreatment post-bronchodilation forced expiratory volume in 1 second (FEV1) is greater than or equal to 25% and less than or equal to 80% of the predicted value;
The member has a documented PiZZ, PiZ (null), or Pi (null, null) (homozygous) AAT deficiency or other phenotype or genotype associated with serum AAT concentrations of less than 11 micromol/L (80 mg/dL by radial immunodiffusion or 50 mg/dL by nephelometry);
The member does not have the PiMZ or PiMS AAT deficiency.
Continuation: Aetna considers continuation of alpha 1-proteinase inhibitor (Aralast NP, Glassia, Prolastin-C, and Zemaira) therapy medically necessary for treatment of emphysema due to alpha 1-antitrypsin (AAT) deficiency when the member is experiencing beneficial clinical response from therapy.

2 Active Policies

AETNA-CPB-0145 — Alpha 1-Proteinase Inhibitors

ANTHEM-CG-MED-23 — CG-MED-23 Home Health

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S9346 — Home infusion therapy, alpha-1-proteinase inhibitor (e.g., prolastin); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem