Does J0174 require prior authorization?

Yes, J0174 requires prior authorization (high confidence). Code explicitly requires prior authorization.

What is the Medicare reimbursement rate for J0174?

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

Backwork Sign up free

`J0174`, Lecanemab-irmb, for intravenous injection, 1 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

Medical records/chart notes documenting diagnosis consistent with NIA-AA criteria (MCI due to AD or mild dementia due to AD) for initial therapy; for continuation documentation that diagnosis of Alzheimer's disease persists (or documentation of progression to moderate/severe with prescriber attestation of shared decision-making).
Submission of medical records documenting one of the following cognitive test scores for initiation: Mini-Mental State Examination (MMSE) score of 20 to 30; Montreal Cognitive Assessment (MoCA) score of 17 to 30; OR Saint Louis University Mental Status (SLUMS) score of 17 to 30.
Submission of medical records documenting presence of amyloid beta pathology by one of the following: positive amyloid PET brain imaging; OR cerebrospinal fluid (CSF) biomarker testing documenting abnormalities suggestive of beta-amyloid accumulation (e.g., Aß42/40 ratio, p-tau181/Aß42 ratio, t-tau/Aß42 ratio).
Baseline brain MRI completed within 12 months prior to initiating treatment (radiology report/film or chart documentation).
Follow-up brain MRI completed after initiation of therapy (documentation of timing and results).
Documentation that other differential diagnoses have been ruled out (e.g., notes ruling out DLB, FTD, vascular dementia, pseudodementia due to mood disorder, vitamin B12 deficiency, encephalopathy, etc.).

Key Coverage Criteria

Intravenous administration of Leqembi (lecanemab-irmb) by a healthcare professional for the treatment of Alzheimer's disease when all applicable criteria below are met.
Initial therapy for patients with a diagnosis (based on NIA-AA criteria) of either: Mild cognitive impairment (MCI) due to Alzheimer's disease; or Mild dementia due to Alzheimer's disease.
Continuation therapy for patients with a diagnosis of Alzheimer's disease (including those who remain MCI or mild dementia due to AD, or those who have progressed to moderate or severe dementia when prescriber attests patient shared in decision-making to continue Leqembi).
Treatment only when presence of amyloid beta pathology has been confirmed (see documentation requirements).
Treatment when baseline brain MRI has been completed within 12 months prior to initiating treatment and required follow-up MRI(s) are completed after initiation as specified in policy.
Leqembi dosing when given must follow the United States FDA approved labeling.

20 Active Policies

ARKBLUE-MONOCLONAL-ANTIBODIES-FOR-TREATMENT-OF-ALZHEIMER-B5054F7992, Monoclonal Antibodies for Treatment of Alzheimer Disease [Aducanumab (e.g., Aduhelm) and Lecanemab (e.g., Leqembi)]

FLORIDA_BLUE-FLBLUE-LEQEMBITM-LECANEMAB-IRMB-348DDD9A08, Leqembi (lecanemab-irmb)

BCBSM-2171624-8B1B85503C, LEQEMBI (LECANEMAB)

HEALTHPARTNERS-CC-ENTRY-247647, Aducanumab (Aduhelm) and lecanemab (Leqembi and Leqembi Iqlik) – Minnesota Health Care Programs

MULTI

POINT32HEALTH-MDMNG-13131, Leqembi (lecanemab)

MULTI

POINT32HEALTH-MDMNG-13141, Leqembi (lecanemab)

MULTI

BCBSNE-X-214-386E82CB39, LEQEMBI

MODA-LEQEMBI-DA7BAB34BB, Leqembi (lecanemab-irmb)

HEALTHNET_OR-HNOR-LECANEMAB-IRMB-LEQEMBI-CP-PHAR-596-18D0483393, Lecanemab-irmb (Leqembi); CP.PHAR.596

BCBSOK-ADM1001.034, Specialty Medication Administration Site of Care

UMR-POL-UMR-leqembi, Leqembi (Lecanemab-Irmb)

SUREST-POL-SUREST-leqembi, Leqembi (Lecanemab-Irmb)

BCBSTN-92bd1a1b7d, Lecanemab-irmb (Leqembi)

EVICORE-MEDICAL_DRUG-BFBBA4DF427A, Leqembi (lecanemab-irmb)

OSCAR-LEQEMBI-LECANEMAB-IRMB-PG138-VER-5-CC89EE876B, Leqembi (lecanemab-irmb) (PG138, Ver. 5)

UHC-POL-leqembi, Leqembi (Lecanemab-Irmb)

UHC-EXCH-MD-LEQEMBI-LECANEMAB-IRMB-INDIVIDUAL-EXCHAN-8950B5B883, Leqembi (Lecanemab-Irmb) – Individual Exchange Medical Benefit Drug Policy

AETNA-CPB-0349, Alzheimer's Disease Tests

BCBSIL-RX501.152, Lecanemab-irmb

BCBSIL-ADM1001.034, Specialty Medication Administration Site of Care

Have a follow-up question?

Ask Backwork about documentation requirements, denial risks, or coverage in your state.

Ask Backwork about J0174 Sign up free

J0174, Lecanemab-irmb, for intravenous injection, 1 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

Medical records/chart notes documenting diagnosis consistent with NIA-AA criteria (MCI due to AD or mild dementia due to AD) for initial therapy; for continuation documentation that diagnosis of Alzheimer's disease persists (or documentation of progression to moderate/severe with prescriber attestation of shared decision-making).
Submission of medical records documenting one of the following cognitive test scores for initiation: Mini-Mental State Examination (MMSE) score of 20 to 30; Montreal Cognitive Assessment (MoCA) score of 17 to 30; OR Saint Louis University Mental Status (SLUMS) score of 17 to 30.
Submission of medical records documenting presence of amyloid beta pathology by one of the following: positive amyloid PET brain imaging; OR cerebrospinal fluid (CSF) biomarker testing documenting abnormalities suggestive of beta-amyloid accumulation (e.g., Aß42/40 ratio, p-tau181/Aß42 ratio, t-tau/Aß42 ratio).
Baseline brain MRI completed within 12 months prior to initiating treatment (radiology report/film or chart documentation).
Follow-up brain MRI completed after initiation of therapy (documentation of timing and results).
Documentation that other differential diagnoses have been ruled out (e.g., notes ruling out DLB, FTD, vascular dementia, pseudodementia due to mood disorder, vitamin B12 deficiency, encephalopathy, etc.).

Key Coverage Criteria

Intravenous administration of Leqembi (lecanemab-irmb) by a healthcare professional for the treatment of Alzheimer's disease when all applicable criteria below are met.
Initial therapy for patients with a diagnosis (based on NIA-AA criteria) of either: Mild cognitive impairment (MCI) due to Alzheimer's disease; or Mild dementia due to Alzheimer's disease.
Continuation therapy for patients with a diagnosis of Alzheimer's disease (including those who remain MCI or mild dementia due to AD, or those who have progressed to moderate or severe dementia when prescriber attests patient shared in decision-making to continue Leqembi).
Treatment only when presence of amyloid beta pathology has been confirmed (see documentation requirements).
Treatment when baseline brain MRI has been completed within 12 months prior to initiating treatment and required follow-up MRI(s) are completed after initiation as specified in policy.
Leqembi dosing when given must follow the United States FDA approved labeling.

20 Active Policies

ARKBLUE-MONOCLONAL-ANTIBODIES-FOR-TREATMENT-OF-ALZHEIMER-B5054F7992, Monoclonal Antibodies for Treatment of Alzheimer Disease [Aducanumab (e.g., Aduhelm) and Lecanemab (e.g., Leqembi)]

FLORIDA_BLUE-FLBLUE-LEQEMBITM-LECANEMAB-IRMB-348DDD9A08, Leqembi (lecanemab-irmb)

BCBSM-2171624-8B1B85503C, LEQEMBI (LECANEMAB)

HEALTHPARTNERS-CC-ENTRY-247647, Aducanumab (Aduhelm) and lecanemab (Leqembi and Leqembi Iqlik) – Minnesota Health Care Programs

MULTI

POINT32HEALTH-MDMNG-13131, Leqembi (lecanemab)

MULTI

POINT32HEALTH-MDMNG-13141, Leqembi (lecanemab)

MULTI

BCBSNE-X-214-386E82CB39, LEQEMBI

MODA-LEQEMBI-DA7BAB34BB, Leqembi (lecanemab-irmb)

HEALTHNET_OR-HNOR-LECANEMAB-IRMB-LEQEMBI-CP-PHAR-596-18D0483393, Lecanemab-irmb (Leqembi); CP.PHAR.596

BCBSOK-ADM1001.034, Specialty Medication Administration Site of Care

UMR-POL-UMR-leqembi, Leqembi (Lecanemab-Irmb)

SUREST-POL-SUREST-leqembi, Leqembi (Lecanemab-Irmb)

BCBSTN-92bd1a1b7d, Lecanemab-irmb (Leqembi)

EVICORE-MEDICAL_DRUG-BFBBA4DF427A, Leqembi (lecanemab-irmb)

OSCAR-LEQEMBI-LECANEMAB-IRMB-PG138-VER-5-CC89EE876B, Leqembi (lecanemab-irmb) (PG138, Ver. 5)

UHC-POL-leqembi, Leqembi (Lecanemab-Irmb)

UHC-EXCH-MD-LEQEMBI-LECANEMAB-IRMB-INDIVIDUAL-EXCHAN-8950B5B883, Leqembi (Lecanemab-Irmb) – Individual Exchange Medical Benefit Drug Policy

AETNA-CPB-0349, Alzheimer's Disease Tests

BCBSIL-RX501.152, Lecanemab-irmb

BCBSIL-ADM1001.034, Specialty Medication Administration Site of Care

Have a follow-up question?

Ask Backwork about documentation requirements, denial risks, or coverage in your state.

Ask Backwork about J0174 Sign up free

`J0174`, Lecanemab-irmb, for intravenous injection, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J0174`, Lecanemab-irmb, for intravenous injection, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J0174, Lecanemab-irmb, for intravenous injection, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J0174, Lecanemab-irmb, for intravenous injection, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J0174`, Lecanemab-irmb, for intravenous injection, 1 mg

`J0174`, Lecanemab-irmb, for intravenous injection, 1 mg