Does J0175 require prior authorization?

Yes, J0175 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for J0175?

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

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`J0175`, Injection, donanemab-azbt, 2 mg

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

The document states the individual must be diagnosed with the FDA-approved indication and meet specific coverage guidelines and applicable safety criteria, but no specific documentation items (e.g., required tests, imaging, or clinical notes) are listed in this policy text.
Provide documentation of amyloid pathology by baseline amyloid PET or lumbar puncture results.
Provide a brain MRI performed within one year prior to initiating treatment.
Submit genetic testing results documenting APP, PSEN1, or PSEN2 mutation when applicable.
Provide clinical documentation supporting early onset Alzheimer’s disease when applicable.
Provide medical records documenting diagnosis of Clinical Stage 3 or 4 Alzheimer’s disease.

Key Coverage Criteria

FDA-approved indication: treatment of Alzheimer's disease.
Treatment with Kisunla should be initiated in patients with mild cognitive impairment (MCI) or mild dementia stage of disease — the population in which treatment was initiated in clinical trials.
When requesting Kisunla, the individual must be diagnosed with the FDA-approved indication and meet the specific coverage guidelines and applicable safety criteria for the covered indication.
Overall coverage statement: Donanemab-azbt is covered for treatment of Alzheimer's disease only when all listed criteria are satisfied.
Age requirement: patient must be 50 years or older.
Diagnosis requirement: patient must have mild cognitive impairment due to Alzheimer's disease or mild Alzheimer's disease dementia.

20 Active Policies

ARKBLUE-DONANEMAB-E-G-KISUNLA-EB90B4D696, Donanemab (e.g., Kisunla)

FLORIDA_BLUE-FLBLUE-KISUNLATM-DONANEMAB-AZBT-765F509D83, Kisunla (Donanemab-Azbt)

BCBSM-2188247-CFBD95DBA3, KISUNLA (DONANEMAB-AZBT)

HEALTHPARTNERS-CC-ENTRY-286110, Donanemab-azbt (Kisunla) – Minnesota Health Care Programs

MULTI

POINT32HEALTH-MDMNG-13051, Kisunla (donanemab-azbt)

MULTI

POINT32HEALTH-MDMNG-13061, Kisunla (donanemab)

MULTI

BCBSNE-X-230-63AF4EC27D, KISUNLA

MODA-ADUHELM-932B1178A2, Anti-amyloid-β monoclonal antibodies: donanemab-azbt (Kisunla)

HEALTHNET_OR-HNOR-DONANEMAB-KISUNLA-CP-PHAR-594-77AB65E4C8, Donanemab (Kisunla); CP.PHAR.594

UMR-POL-UMR-kisunla, Kisunla (Donanemab-Azbt)

SUREST-POL-SUREST-kisunla, Kisunla (Donanemab-Azbt)

BCBSTN-ca38dd1919, Donanemab-azbt (Kisunla)

EVICORE-MEDICAL_DRUG-9A87F1829DED, Kisunla (donanemab-azbt)

OSCAR-KISUNLA-DONANEMAB-AZBT-PG238-VER-2-08682B5E69, Kisunla (donanemab-azbt) (PG238, Ver. 2)

UHC-POL-kisunla, Kisunla (Donanemab-Azbt)

UHC-EXCH-MD-KISUNLATM-DONANEMAB-AZBT-INDIVIDUAL-EXCH-194353780B, Kisunla (Donanemab-Azbt) – Individual Exchange Medical Benefit Drug Policy

BCBSIL-RX501.177, Donanemab-azbt

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

BCBSMT-RX501.177, Donanemab-azbt

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

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J0175, Injection, donanemab-azbt, 2 mg

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

The document states the individual must be diagnosed with the FDA-approved indication and meet specific coverage guidelines and applicable safety criteria, but no specific documentation items (e.g., required tests, imaging, or clinical notes) are listed in this policy text.
Provide documentation of amyloid pathology by baseline amyloid PET or lumbar puncture results.
Provide a brain MRI performed within one year prior to initiating treatment.
Submit genetic testing results documenting APP, PSEN1, or PSEN2 mutation when applicable.
Provide clinical documentation supporting early onset Alzheimer’s disease when applicable.
Provide medical records documenting diagnosis of Clinical Stage 3 or 4 Alzheimer’s disease.

Key Coverage Criteria

FDA-approved indication: treatment of Alzheimer's disease.
Treatment with Kisunla should be initiated in patients with mild cognitive impairment (MCI) or mild dementia stage of disease — the population in which treatment was initiated in clinical trials.
When requesting Kisunla, the individual must be diagnosed with the FDA-approved indication and meet the specific coverage guidelines and applicable safety criteria for the covered indication.
Overall coverage statement: Donanemab-azbt is covered for treatment of Alzheimer's disease only when all listed criteria are satisfied.
Age requirement: patient must be 50 years or older.
Diagnosis requirement: patient must have mild cognitive impairment due to Alzheimer's disease or mild Alzheimer's disease dementia.

20 Active Policies

ARKBLUE-DONANEMAB-E-G-KISUNLA-EB90B4D696, Donanemab (e.g., Kisunla)

FLORIDA_BLUE-FLBLUE-KISUNLATM-DONANEMAB-AZBT-765F509D83, Kisunla (Donanemab-Azbt)

BCBSM-2188247-CFBD95DBA3, KISUNLA (DONANEMAB-AZBT)

HEALTHPARTNERS-CC-ENTRY-286110, Donanemab-azbt (Kisunla) – Minnesota Health Care Programs

MULTI

POINT32HEALTH-MDMNG-13051, Kisunla (donanemab-azbt)

MULTI

POINT32HEALTH-MDMNG-13061, Kisunla (donanemab)

MULTI

BCBSNE-X-230-63AF4EC27D, KISUNLA

MODA-ADUHELM-932B1178A2, Anti-amyloid-β monoclonal antibodies: donanemab-azbt (Kisunla)

HEALTHNET_OR-HNOR-DONANEMAB-KISUNLA-CP-PHAR-594-77AB65E4C8, Donanemab (Kisunla); CP.PHAR.594

UMR-POL-UMR-kisunla, Kisunla (Donanemab-Azbt)

SUREST-POL-SUREST-kisunla, Kisunla (Donanemab-Azbt)

BCBSTN-ca38dd1919, Donanemab-azbt (Kisunla)

EVICORE-MEDICAL_DRUG-9A87F1829DED, Kisunla (donanemab-azbt)

OSCAR-KISUNLA-DONANEMAB-AZBT-PG238-VER-2-08682B5E69, Kisunla (donanemab-azbt) (PG238, Ver. 2)

UHC-POL-kisunla, Kisunla (Donanemab-Azbt)

UHC-EXCH-MD-KISUNLATM-DONANEMAB-AZBT-INDIVIDUAL-EXCH-194353780B, Kisunla (Donanemab-Azbt) – Individual Exchange Medical Benefit Drug Policy

BCBSIL-RX501.177, Donanemab-azbt

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

BCBSMT-RX501.177, Donanemab-azbt

BCBSMT-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 J0175 Sign up free

`J0175`, Injection, donanemab-azbt, 2 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J0175`, Injection, donanemab-azbt, 2 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J0175, Injection, donanemab-azbt, 2 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J0175, Injection, donanemab-azbt, 2 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J0175`, Injection, donanemab-azbt, 2 mg

`J0175`, Injection, donanemab-azbt, 2 mg