Does J0735 require prior authorization?

No, J0735 does not require prior authorization (high confidence). Covered without prior authorization.

What is the Medicare reimbursement rate for J0735?

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

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`J0735`, Injection, clonidine hydrochloride, 1 mg

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

Use of appropriate diagnosis coding (policy references N39.44 - Nocturnal enuresis) and appropriate HCPCS (S8270 for enuresis alarm; J2597 for desmopressin injection) when selection criteria are met.
Clinical notes supporting diagnosis of primary nocturnal enuresis (e.g., absence of daytime symptoms) and linkage to ICD-10 code N39.44 when applicable.

Physician examination documenting that physical or organic causes for nocturnal enuresis (e.g., renal disease, neurological disease, infection) have been evaluated and ruled out.

Documentation of the member's age (must be ≥7 years for bedwetting alarm; >5 years for desmopressin).

Documentation of bedwetting frequency meeting criteria: either minimum of 3 wet nights per week in the previous month, or at least 1 wetting episode weekly for 1 year.

For desmopressin, documentation that non-pharmacologic therapies were tried and failed (examples: fluid and food intake advice, enuresis alarm treatment) OR documentation that such therapies were refused or the patient is unlikely to adhere to them.

Key Coverage Criteria

Use of a bedwetting alarm as durable medical equipment for the treatment of primary nocturnal enuresis when ALL of the following criteria are met: member is 7 years of age or older; member has experienced bedwetting a minimum of 3 nights a week in the previous month, or at least 1 wetting episode weekly for 1 year; member has no daytime wetting; member has been examined by a physician, and physical or organic causes for nocturnal enuresis (e.g., renal disease, neurological disease, infection, et [...]
Desmopressin for the treatment of primary nocturnal enuresis in children older than 5 years whose bedwetting has not responded to non-pharmacologic therapies (e.g., fluid and food intake advice, enuresis alarm treatment), or when non-pharmacologic therapies were refused or the child is unlikely to adhere to enuresis alarm treatment.
HCPCS J2597 (injection, desmopressin acetate) — covered if selection criteria for desmopressin are met.
HCPCS S8270 (enuresis alarm, using auditory buzzer and/or vibration device) — covered if selection criteria for bedwetting alarm are met.
ICD-10 code N39.44 (Nocturnal enuresis) — listed as a covered diagnosis when selection criteria are met.
Diagnosis and treatment of pre-menstrual syndrome (PMS) and pre-menstrual dysphoric disorder (PMDD).

2 Active Policies

AETNA-CPB-0431, Enuresis

AETNA-CPB-0512, Premenstrual Syndrome and Premenstrual Dysphoric Disorder

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J0735, Injection, clonidine hydrochloride, 1 mg