Does J0224 require prior authorization?

Yes, J0224 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for J0224?

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

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`J0224`, Injection, lumasiran, 0.5 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

Submit medical chart notes confirming PH1 diagnosis.

Key Coverage Criteria

Indication: Oxlumo (Lumasiran) is covered for treatment of PH1 in patients who meet all of the following initial-therapy criteria: diagnosis of PH1; not receiving Oxlumo with Rivfloza; dosing per FDA labeling; initial authorization up to 12 months. For continuation, require positive clinical response, not receiving Rivfloza with Oxlumo, dosing per FDA labeling, and reauthorization up to 12 months.
Covered when hospital outpatient facility infusion services for specialty medications and IVIG/SCIG therapy are considered medically necessary and the member meets the specific clinical criteria described in the policy.
This policy addresses only the determination of medical necessity for the hospital outpatient setting for infusion and injectable therapy; the medical necessity of the pharmacologic or biologic medication itself may be reviewed separately.
Requests for select medications intended for administration in a hospital outpatient setting will be directed to a preferred alternative site of care (non-hospital affiliated outpatient facility or home).
This policy addresses only the determination of medical necessity for the hospital outpatient setting for infusion and injectable therapy; the medical necessity of the pharmacologic or biologic medication itself may be reviewed separately.
Requests for select medications intended for administration in a hospital outpatient setting will be directed to a preferred alternative site of care (non-hospital affiliated outpatient facility or home).

20 Active Policies

ARKBLUE-LUMASIRAN-E-G-OXLUMO-00600A5CD1, Lumasiran (e.g., Oxlumo)

FLORIDA_BLUE-FLBLUE-LUMASIRAN-OXLUMO-0E9C520CE6, Lumasiran (Oxlumo)

BCBSM-2142720-C73C06CC55, OXLUMO (LUMASIRAN)

BCBSMS-S-5-01-624-A4B22EEB27, State and School Employees' Health Insurance Plan - Oxlumo (lumasiran)

BCBSMS-L-5-01-624-F51F2213EC, Oxlumo (lumasiran)

POINT32HEALTH-MDMNG-13426, Oxlumo (lumasiran)

MULTI

HEALTHPARTNERS-CC-ENTRY-234243, Lumasiran (Oxlumo)

MULTI

POINT32HEALTH-MDMNG-13416, Oxlumo (lumasiran)

MULTI

BCBSND-LUMASIRAN-OXLUMO-621A953916, Lumasiran Oxlumo

MODA-OXLUMO-34A5BD2C5A, Oxlumo (lumasiran)

HEALTHNET_OR-HNOR-LUMASIRAN-OXLUMO-CP-PHAR-473-8F807E7A68, Lumasiran (Oxlumo); CP.PHAR.473

IBX-MEDICARE-ADVANTAGE-MA08-131C-8E43D30E58, Lumasiran (Oxlumo)

IBX-COMMERCIAL-08-01-74C-FE99A8E393, Lumasiran (Oxlumo)

UHC-EXCH-MD-OXLUMO-LUMASIRAN-AND-RIVFLOZA-NEDOSIRAN-81CBD9E504, Oxlumo (Lumasiran) and Rivfloza (Nedosiran) – Commercial and Individual Exchange Medical Benefit Drug Policy

UHC-POL-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care

UHC-POL-oxlumo, Oxlumo (Lumasiran) and Rivfloza (Nedosiran)

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

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

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

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

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J0224, Injection, lumasiran, 0.5 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

Submit medical chart notes confirming PH1 diagnosis.

Key Coverage Criteria

Indication: Oxlumo (Lumasiran) is covered for treatment of PH1 in patients who meet all of the following initial-therapy criteria: diagnosis of PH1; not receiving Oxlumo with Rivfloza; dosing per FDA labeling; initial authorization up to 12 months. For continuation, require positive clinical response, not receiving Rivfloza with Oxlumo, dosing per FDA labeling, and reauthorization up to 12 months.
Covered when hospital outpatient facility infusion services for specialty medications and IVIG/SCIG therapy are considered medically necessary and the member meets the specific clinical criteria described in the policy.
This policy addresses only the determination of medical necessity for the hospital outpatient setting for infusion and injectable therapy; the medical necessity of the pharmacologic or biologic medication itself may be reviewed separately.
Requests for select medications intended for administration in a hospital outpatient setting will be directed to a preferred alternative site of care (non-hospital affiliated outpatient facility or home).
This policy addresses only the determination of medical necessity for the hospital outpatient setting for infusion and injectable therapy; the medical necessity of the pharmacologic or biologic medication itself may be reviewed separately.
Requests for select medications intended for administration in a hospital outpatient setting will be directed to a preferred alternative site of care (non-hospital affiliated outpatient facility or home).

20 Active Policies

ARKBLUE-LUMASIRAN-E-G-OXLUMO-00600A5CD1, Lumasiran (e.g., Oxlumo)

FLORIDA_BLUE-FLBLUE-LUMASIRAN-OXLUMO-0E9C520CE6, Lumasiran (Oxlumo)

BCBSM-2142720-C73C06CC55, OXLUMO (LUMASIRAN)

BCBSMS-S-5-01-624-A4B22EEB27, State and School Employees' Health Insurance Plan - Oxlumo (lumasiran)

BCBSMS-L-5-01-624-F51F2213EC, Oxlumo (lumasiran)

POINT32HEALTH-MDMNG-13426, Oxlumo (lumasiran)

MULTI

HEALTHPARTNERS-CC-ENTRY-234243, Lumasiran (Oxlumo)

MULTI

POINT32HEALTH-MDMNG-13416, Oxlumo (lumasiran)

MULTI

BCBSND-LUMASIRAN-OXLUMO-621A953916, Lumasiran Oxlumo

MODA-OXLUMO-34A5BD2C5A, Oxlumo (lumasiran)

HEALTHNET_OR-HNOR-LUMASIRAN-OXLUMO-CP-PHAR-473-8F807E7A68, Lumasiran (Oxlumo); CP.PHAR.473

IBX-MEDICARE-ADVANTAGE-MA08-131C-8E43D30E58, Lumasiran (Oxlumo)

IBX-COMMERCIAL-08-01-74C-FE99A8E393, Lumasiran (Oxlumo)

UHC-EXCH-MD-OXLUMO-LUMASIRAN-AND-RIVFLOZA-NEDOSIRAN-81CBD9E504, Oxlumo (Lumasiran) and Rivfloza (Nedosiran) – Commercial and Individual Exchange Medical Benefit Drug Policy

UHC-POL-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care

UHC-POL-oxlumo, Oxlumo (Lumasiran) and Rivfloza (Nedosiran)

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

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

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

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

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

Ask Backwork about J0224 Sign up free

`J0224`, Injection, lumasiran, 0.5 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J0224`, Injection, lumasiran, 0.5 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J0224, Injection, lumasiran, 0.5 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J0224, Injection, lumasiran, 0.5 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J0224`, Injection, lumasiran, 0.5 mg

`J0224`, Injection, lumasiran, 0.5 mg