Does J0202 require prior authorization?

Yes, J0202 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for J0202?

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

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`J0202`, Injection, alemtuzumab, 1 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

For UB-04 hospital outpatient (Part B) claims, include diagnosis in Box 66 (ICD-10-CM G35.A or G35.C1 where applicable), HCPCS drug code in Field 44, narrative (Field 80 or electronic equivalent) containing NDC, trade and generic drug name, dose administered, and route of administration.
For CMS-1500 (Part B) claims, include diagnosis in Box 21 (ICD-10-CM G35.A or G35.C1 where applicable), HCPCS drug code in Box 24D, and narrative in Box 19 (or electronic equivalent) with NDC, trade and generic drug name, dose administered, and route of administration.
Include HCPCS J0202 (Injection, alemtuzumab 1 mg) for applicable dates of service and list the single-use vial NDC 58468-0200-1 or 58468-0200-01 in the claim narrative.
Claims must reflect administered dose as 12 mg per date of service consistent with FDA labeling; discrepancies in administered dose, wastage, or NDC will result in claim rejection.
Documentation of diagnosis: record confirming diagnosis of relapsing forms of multiple sclerosis (e.g., relapsing‑remitting MS, active secondary‑progressive MS).
For treatment‑naïve requests: documentation of prior trials showing history of failure following a trial for at least 4 weeks or history of intolerance to at least two listed disease modifying therapies (explicitly list agents tried and dates/duration and reason for failure/intolerance).

Key Coverage Criteria

Treatment of relapsing forms of multiple sclerosis with documented diagnosis code ICD-10-CM G35.A or G35.C1 on the claim for dates of service on or after 10/01/2015.
Therapy must follow FDA-labeled dosing: 12 mg IV once daily for 5 consecutive days for the first course, then 12 mg IV once daily for 3 consecutive days approximately one year after the first course.
Lemtrada (alemtuzumab) is proven and medically necessary for treatment of relapsing forms of multiple sclerosis (MS) (e.g., relapsing-remitting MS, active secondary-progressive MS) when all of the following criteria are met:
Diagnosis of relapsing forms of multiple sclerosis (MS) (e.g., relapsing-remitting MS, active secondary-progressive MS).
Treatment‑naïve to alemtuzumab: Patient has history of failure following a trial for at least 4 weeks or history of intolerance to at least two of the following: interferon β-1a (Avonex or Rebif), interferon β-1b (Betaseron or Extavia), glatiramer acetate (Copaxone or Glatopa), dimethyl fumarate (Tecfidera), teriflunomide (Aubagio), fingolimod (Gilenya), peginterferon beta-1a (Plegridy), natalizumab (Tysabri), ocrelizumab (Ocrevus), rituximab (Riabni, Rituxan, Ruxience, & Truxima), siponimod (Ma [...]
Patient has not been previously treated with alemtuzumab (for initial treatment).

20 Active Policies

ARKBLUE-ALEMTUZUMAB-E-G-LEMTRADA-2FCE87D427, Alemtuzumab (e.g., Lemtrada)

FLORIDA_BLUE-FLBLUE-ALEMTUZUMAB-LEMTRADA-FEC717670D, Alemtuzumab (Lemtrada)

BCBSLA-00448-18173A2565, 00448 alemtuzumab (Lemtrada)

HEALTHPARTNERS-CC-ENTRY-205426, Alemtuzumab (Lemtrada) – Minnesota Health Care Programs

MULTI

HEALTHPARTNERS-CC-AENTRY-045637, Alemtuzumab (Lemtrada)

MULTI

BCBSND-ALEMTUZUMAB-LEMTRADA-2CA60EF77F, Alemtuzumab Lemtrada

BCBSNJ-DRUGS-127-9B8A5CDC04, Lemtrada (Alemtuzumab)

HEALTHNET_OR-HNOR-ALEMTUZUMAB-LEMTRADA-CP-PHAR-243-C5F9CE15D6, Alemtuzumab (Lemtrada); CP.PHAR.243

MODA-LEMTRADA-D8DAE49786, Lemtrada (alemtuzumab)

IBX-MEDICARE-ADVANTAGE-MA08-015E-4C2DDAB256, Alemtuzumab (Lemtrada)

IBX-COMMERCIAL-08-01-22E-60433548F7, Alemtuzumab (Lemtrada)

AMERIHEALTH-MEDICARE-ADVANTAGE-MA08-015E-2AECB00C21, Alemtuzumab (Lemtrada)

BCBSTN-452e349934, Alemtuzumab (Lemtrada)

EVICORE-MEDICAL_DRUG-5975D3A92719, Lemtrada (alemtuzumab)

OSCAR-LEMTRADA-ALEMTUZUMAB-PG226-VER-4-1515227225, Lemtrada (Alemtuzumab) (PG226, Ver. 4)

UHC-COMM-MD-LEMTRADA-ALEMTUZUMAB-COMMUNITY-PLAN-MEDI-65F83A301F, Lemtrada (Alemtuzumab) – Community Plan Medical Benefit Drug Policy

A55310, Billing and Coding: Instructions for Lemtrada (alemtuzumab) When Used in the Treatment of Relapsing Multiple Sclerosis

UHC-EXCH-MD-LEMTRADA-ALEMTUZUMAB-COMMERCIAL-AND-INDI-9430CC0509, Lemtrada (Alemtuzumab) – Commercial and Individual Exchange Medical Benefit Drug Policy

UHC-POL-lemtrada-alemtuzumab, Lemtrada (Alemtuzumab)

AETNA-CPB-0732, Guillain-Barre Syndrome Treatments

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

Ask Backwork about J0202 Sign up free

J0202, Injection, alemtuzumab, 1 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

For UB-04 hospital outpatient (Part B) claims, include diagnosis in Box 66 (ICD-10-CM G35.A or G35.C1 where applicable), HCPCS drug code in Field 44, narrative (Field 80 or electronic equivalent) containing NDC, trade and generic drug name, dose administered, and route of administration.
For CMS-1500 (Part B) claims, include diagnosis in Box 21 (ICD-10-CM G35.A or G35.C1 where applicable), HCPCS drug code in Box 24D, and narrative in Box 19 (or electronic equivalent) with NDC, trade and generic drug name, dose administered, and route of administration.
Include HCPCS J0202 (Injection, alemtuzumab 1 mg) for applicable dates of service and list the single-use vial NDC 58468-0200-1 or 58468-0200-01 in the claim narrative.
Claims must reflect administered dose as 12 mg per date of service consistent with FDA labeling; discrepancies in administered dose, wastage, or NDC will result in claim rejection.
Documentation of diagnosis: record confirming diagnosis of relapsing forms of multiple sclerosis (e.g., relapsing‑remitting MS, active secondary‑progressive MS).
For treatment‑naïve requests: documentation of prior trials showing history of failure following a trial for at least 4 weeks or history of intolerance to at least two listed disease modifying therapies (explicitly list agents tried and dates/duration and reason for failure/intolerance).

Key Coverage Criteria

Treatment of relapsing forms of multiple sclerosis with documented diagnosis code ICD-10-CM G35.A or G35.C1 on the claim for dates of service on or after 10/01/2015.
Therapy must follow FDA-labeled dosing: 12 mg IV once daily for 5 consecutive days for the first course, then 12 mg IV once daily for 3 consecutive days approximately one year after the first course.
Lemtrada (alemtuzumab) is proven and medically necessary for treatment of relapsing forms of multiple sclerosis (MS) (e.g., relapsing-remitting MS, active secondary-progressive MS) when all of the following criteria are met:
Diagnosis of relapsing forms of multiple sclerosis (MS) (e.g., relapsing-remitting MS, active secondary-progressive MS).
Treatment‑naïve to alemtuzumab: Patient has history of failure following a trial for at least 4 weeks or history of intolerance to at least two of the following: interferon β-1a (Avonex or Rebif), interferon β-1b (Betaseron or Extavia), glatiramer acetate (Copaxone or Glatopa), dimethyl fumarate (Tecfidera), teriflunomide (Aubagio), fingolimod (Gilenya), peginterferon beta-1a (Plegridy), natalizumab (Tysabri), ocrelizumab (Ocrevus), rituximab (Riabni, Rituxan, Ruxience, & Truxima), siponimod (Ma [...]
Patient has not been previously treated with alemtuzumab (for initial treatment).

20 Active Policies

ARKBLUE-ALEMTUZUMAB-E-G-LEMTRADA-2FCE87D427, Alemtuzumab (e.g., Lemtrada)

FLORIDA_BLUE-FLBLUE-ALEMTUZUMAB-LEMTRADA-FEC717670D, Alemtuzumab (Lemtrada)

BCBSLA-00448-18173A2565, 00448 alemtuzumab (Lemtrada)

HEALTHPARTNERS-CC-ENTRY-205426, Alemtuzumab (Lemtrada) – Minnesota Health Care Programs

MULTI

HEALTHPARTNERS-CC-AENTRY-045637, Alemtuzumab (Lemtrada)

MULTI

BCBSND-ALEMTUZUMAB-LEMTRADA-2CA60EF77F, Alemtuzumab Lemtrada

BCBSNJ-DRUGS-127-9B8A5CDC04, Lemtrada (Alemtuzumab)

HEALTHNET_OR-HNOR-ALEMTUZUMAB-LEMTRADA-CP-PHAR-243-C5F9CE15D6, Alemtuzumab (Lemtrada); CP.PHAR.243

MODA-LEMTRADA-D8DAE49786, Lemtrada (alemtuzumab)

IBX-MEDICARE-ADVANTAGE-MA08-015E-4C2DDAB256, Alemtuzumab (Lemtrada)

IBX-COMMERCIAL-08-01-22E-60433548F7, Alemtuzumab (Lemtrada)

AMERIHEALTH-MEDICARE-ADVANTAGE-MA08-015E-2AECB00C21, Alemtuzumab (Lemtrada)

BCBSTN-452e349934, Alemtuzumab (Lemtrada)

EVICORE-MEDICAL_DRUG-5975D3A92719, Lemtrada (alemtuzumab)

OSCAR-LEMTRADA-ALEMTUZUMAB-PG226-VER-4-1515227225, Lemtrada (Alemtuzumab) (PG226, Ver. 4)

UHC-COMM-MD-LEMTRADA-ALEMTUZUMAB-COMMUNITY-PLAN-MEDI-65F83A301F, Lemtrada (Alemtuzumab) – Community Plan Medical Benefit Drug Policy

A55310, Billing and Coding: Instructions for Lemtrada (alemtuzumab) When Used in the Treatment of Relapsing Multiple Sclerosis

UHC-EXCH-MD-LEMTRADA-ALEMTUZUMAB-COMMERCIAL-AND-INDI-9430CC0509, Lemtrada (Alemtuzumab) – Commercial and Individual Exchange Medical Benefit Drug Policy

UHC-POL-lemtrada-alemtuzumab, Lemtrada (Alemtuzumab)

AETNA-CPB-0732, Guillain-Barre Syndrome Treatments

Have a follow-up question?

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

Ask Backwork about J0202 Sign up free

`J0202`, Injection, alemtuzumab, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J0202`, Injection, alemtuzumab, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J0202, Injection, alemtuzumab, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J0202, Injection, alemtuzumab, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J0202`, Injection, alemtuzumab, 1 mg

`J0202`, Injection, alemtuzumab, 1 mg