Does J0598 require prior authorization?

Yes, J0598 requires prior authorization (high confidence). Code explicitly requires prior authorization.

What is the Medicare reimbursement rate for J0598?

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

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`J0598`, Injection, c-1 esterase inhibitor (human), cinryze, 10 units

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

Laboratory documentation of HAE diagnosis: either C1-INH antigenic level below the laboratory lower limit of normal OR C1-INH functional level below the laboratory lower limit of normal (for Type I/II HAE).
If C1-INH levels are normal: genetic testing results confirming presence of variant(s) in one of the specified genes (factor XII, angiopoietin-1, plasminogen-1, kininogen-1, myoferlin, heparan sulfate-glucosamine 3-O-sulfotransferase 6).

Key Coverage Criteria

Treatment of an acute hereditary angioedema (HAE) attack with Berinert (C1 esterase inhibitor, human), Ruconest (C1 esterase inhibitor, recombinant), or Kalbitor (ecallantide) when: (a) used for treatment of an acute HAE attack; and (b) not used in combination with other approved treatments for acute HAE attacks (e.g., Berinert, Firazyr, Kalbitor, or Ruconest).
Initial therapy medical necessity criteria for Berinert, Ruconest, and Kalbitor when all of the following are met: diagnosis of hereditary angioedema (HAE) confirmed by either (a) C1 inhibitor (C1-INH) deficiency or dysfunction (Type I or II HAE) documented by C1-INH antigenic level below the lower limit of normal OR C1-INH functional level below the lower limit of normal; OR (b) normal C1 inhibitor levels and either a confirmed pathogenic variant in one of the listed genes (factor XII, angiopoi [...]
Berinert is FDA-labeled for treatment of acute abdominal, facial, or laryngeal HAE attacks in adult and pediatric patients (as noted in FDA section).
Ruconest is FDA-labeled for treatment of acute attacks in adult and adolescent patients with HAE (effectiveness not established in HAE patients with laryngeal attacks).
Kalbitor (ecallantide) is FDA-labeled for treatment of acute HAE attacks in patients 12 years of age and older.
Cinryze (C1 esterase inhibitor, human) is indicated for routine prophylaxis against angioedema attacks in adults, adolescents, and pediatric patients 6 years of age and older (note: policy distinguishes coverage between Medical Necessity Plans and Non‑Medical Necessity Plans).

18 Active Policies

BCBSLA-00277-092AB18A36, 00277 C1 Esterase Inhibitor (Cinryze, Haegarda)

POINT32HEALTH-MDMNG-12611, Cinryze (C1 esterase inhibitor [Human])

MULTI

POINT32HEALTH-MDMNG-12621, Cinryze (C1 esterase inhibitor)

MULTI

BCBSNJ-DRUGS-063-5CE01BD5D5, Drug Therapy for Hereditary Angioedema [Cinryze, Berinert, Haegarda (Human C1 Inhibitor), Kalbitor (Ecallantide), Firazyr (Icatibant), Ruconest (C1 Esterase Inhibitor [Recombinant]), Takhzyro (lanadelumab-flyo)]

HEALTHNET_OR-HNOR-C1-ESTERASE-INHIBITORS-BERINERT-CINRYZE-HAEGARDA-RUCONES-B71BA98422, C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda, Ruconest); CP.PHAR.202

MODA-CINRYZE-877805EAAA, Cinryze (C1 Esterase Inhibitor, Human)

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

BCBSOK-RX504.013, Management of Hereditary Angioedema (HAE) with C1 Esterase Inhibitor, Human and Ecallantide

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

UHC-POL-hereditary-angioedema-treatment-prophylaxis, Hereditary Angioedema (HAE), Treatment and Prophylaxis

SUREST-POL-SUREST-hereditary-angioedema-treatment-prophylaxis, Hereditary Angioedema (HAE), Treatment and Prophylaxis

EVICORE-MEDICAL_DRUG-F499F8F1EF4F, Cinryze (C1 esterase inhibitor [human])

UMR-POL-UMR-hereditary-angioedema-treatment-prophylaxis, Hereditary Angioedema (HAE), Treatment and Prophylaxis

BCBSIL-RX504.013, Management of Hereditary Angioedema (HAE) with C1 Esterase Inhibitor, Human and Ecallantide

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

BCBSMT-RX504.013, Management of Hereditary Angioedema (HAE) with C1 Esterase Inhibitor, Human and Ecallantide

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

BCBSNM-RX504.013, Management of Hereditary Angioedema (HAE) with C1 Esterase Inhibitor, Human and Ecallantide

`J0598`, Injection, c-1 esterase inhibitor (human), cinryze, 10 units

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

18 Active Policies

Related Codes

Have a follow-up question?

J0598, Injection, c-1 esterase inhibitor (human), cinryze, 10 units

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

18 Active Policies

Related Codes

Have a follow-up question?

`J0598`, Injection, c-1 esterase inhibitor (human), cinryze, 10 units