Does J0791 require prior authorization?

Yes, J0791 requires prior authorization (high confidence). Code explicitly requires prior authorization.

What is the Medicare reimbursement rate for J0791?

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

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`J0791`, Injection, crizanlizumab-tmca, 5 mg

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

Documentation of patient age (must be ≥16 years).
Clinical documentation of at least one sickle cell-related crisis in the previous 12 months (e.g., medical records, ED visits, hospitalizations).
Documentation of hydroxyurea status: currently receiving hydroxyurea OR evidence of inadequate efficacy or significant intolerance to hydroxyurea OR documentation that the patient is not a candidate for hydroxyurea (examples provided: pregnant or planning to become pregnant, immunosuppressive condition such as cancer).
Documentation that Adakveo is prescribed by or in consultation with a physician who specializes in the treatment of sickle cell disease (e.g., hematologist) — e.g., specialist note or consult documentation.
For re-authorization: documentation of clinical benefit from Adakveo therapy with examples such as reduction in number of vaso-occlusive crises/sickle cell-related crises, delay in time to sickle cell-related crisis, or reduction in number of days in the hospital.
Medication administration record confirming dosing per recommended schedule: 5 mg/kg IV over 30 minutes at Week 0, Week 2, and every 4 weeks thereafter.

Key Coverage Criteria

Adakveo is indicated to reduce the frequency of vaso-occlusive crises (VOCs) in adults and pediatric patients aged 16 years and older with sickle cell disease.
Initial authorization requires ALL of the following: Is 16 years of age or older; Has had at least one sickle cell-related crisis in the previous 12 months; Meets one of the following: Is currently receiving hydroxyurea; Has had inadequate efficacy or significant intolerance with hydroxyurea; Is not a candidate for hydroxyurea (i.e., pregnant or planning to become pregnant, has immunosuppressive condition [e.g., cancer]); Adakveo is prescribed by or in consultation with a physician who specializ [...]
Re-authorization requires ALL of the following: Is 16 years of age or older; Is receiving clinical benefit from Adakveo therapy (e.g., reduction in the number of vaso-occlusive crises/sickle cell-related crises, delay in time to sickle cell-related crisis, reduction in number of days in the hospital); Adakveo is prescribed by or in consultation with a physician who specializes in the treatment of sickle cell disease (e.g., a hematologist).
Adakveo is indicated to reduce the frequency of vaso-occlusive crises (VOCs) in adults and pediatric patients aged 16 years and older with sickle cell disease.
Indication: Crizanlizumab-tmca (Adakveo) is indicated for patients aged 16 years and older with sickle cell disease."
Indication for Adakveo (crizanlizumab-tmca): Patient has SCD with insufficient response to at least 3 months of hydroxyurea (or intolerance/contraindication) AND experienced two or more vaso-occlusive crises (VOC) in the prior year despite adherence to hydroxyurea therapy.

20 Active Policies

ARKBLUE-CRIZANLIZUMAB-E-G-ADAKVEO-BD08795C03, Crizanlizumab (e.g., Adakveo)

FLORIDA_BLUE-FLBLUE-CRIZANLIZUMAB-TMCA-ADAKVEO-FC6BC8DE96, Crizanlizumab-tmca (Adakveo)

BCBSLA-00704-4FB1FB841C, 00704 Novel Treatments for Sickle Cell Disease (Adakveo)

BCBSM-2117665-7247110E80, ADAKVEO (CRIZANLIZUMAB-TMCA)

BCBSMS-S-5-01-555-7C2ED4A9F8, State and School Employees' Health Insurance Plan - Adakveo (crizanlizumab-tmca)

BCBSMS-L-5-01-555-10E514B803, Adakveo (crizanlizumab-tmca)

HEALTHPARTNERS-CC-ENTRY-226968, Crizanlizumab-tmca (Adakveo)

MULTI

POINT32HEALTH-MDMNG-12191, Adakveo (crizanlizumab-tmca)

MULTI

BCBSND-CRIZANLIZUMAB-TMCA-ADAKVEO-E50F3C8ECD, Crizanlizumab Tmca Adakveo

BCBSNJ-DRUGS-198-09BF92D8E7, Crizanlizumab-tmca (Adakveo)

MODA-ADAKVEO-7765100610, Adakveo (crizanlizumab-tmca)

HEALTHNET_OR-HNOR-CRIZANLIZUMAB-TMCA-ADAKVEO-CP-PHAR-449-95427FC9FE, Crizanlizumab-tmca (Adakveo); CP.PHAR.449

IBX-MEDICARE-ADVANTAGE-MA08-109C-9ADA5F4D92, Crizanlizumab-tmca (Adakveo)

IBX-COMMERCIAL-08-00-04B-1BBC25B7A3, Crizanlizumab-tmca (Adakveo)

AMERIHEALTH-MEDICARE-ADVANTAGE-MA08-109C-B9DE59830A, Crizanlizumab-tmca (Adakveo)

BCBSTN-1146b033fb, Crizanlizumab-tmca(Adakveo)

EVICORE-MEDICAL_DRUG-76936323150D, Adakveo (crizanlizumab-tmca)

OSCAR-ADAKVEO-CRIZANLIZUMAB-PG193-VER-2-9CA2C2F2D2, Adakveo (crizanlizumab) (PG193, Ver. 2)

UHC-COMM-MD-ADAKVEO-CRIZANLIZUMAB-TMCA-COMMUNITY-PLA-2162BFC0F5, Adakveo (Crizanlizumab-Tmca) – Community Plan Medical Benefit Drug Policy

UHC-POL-adakveo-crizanlizumab-tmca, Adakveo (Crizanlizumab-Tmca)

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J0791, Injection, crizanlizumab-tmca, 5 mg

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

Documentation of patient age (must be ≥16 years).
Clinical documentation of at least one sickle cell-related crisis in the previous 12 months (e.g., medical records, ED visits, hospitalizations).
Documentation of hydroxyurea status: currently receiving hydroxyurea OR evidence of inadequate efficacy or significant intolerance to hydroxyurea OR documentation that the patient is not a candidate for hydroxyurea (examples provided: pregnant or planning to become pregnant, immunosuppressive condition such as cancer).
Documentation that Adakveo is prescribed by or in consultation with a physician who specializes in the treatment of sickle cell disease (e.g., hematologist) — e.g., specialist note or consult documentation.
For re-authorization: documentation of clinical benefit from Adakveo therapy with examples such as reduction in number of vaso-occlusive crises/sickle cell-related crises, delay in time to sickle cell-related crisis, or reduction in number of days in the hospital.
Medication administration record confirming dosing per recommended schedule: 5 mg/kg IV over 30 minutes at Week 0, Week 2, and every 4 weeks thereafter.

Key Coverage Criteria

Adakveo is indicated to reduce the frequency of vaso-occlusive crises (VOCs) in adults and pediatric patients aged 16 years and older with sickle cell disease.
Initial authorization requires ALL of the following: Is 16 years of age or older; Has had at least one sickle cell-related crisis in the previous 12 months; Meets one of the following: Is currently receiving hydroxyurea; Has had inadequate efficacy or significant intolerance with hydroxyurea; Is not a candidate for hydroxyurea (i.e., pregnant or planning to become pregnant, has immunosuppressive condition [e.g., cancer]); Adakveo is prescribed by or in consultation with a physician who specializ [...]
Re-authorization requires ALL of the following: Is 16 years of age or older; Is receiving clinical benefit from Adakveo therapy (e.g., reduction in the number of vaso-occlusive crises/sickle cell-related crises, delay in time to sickle cell-related crisis, reduction in number of days in the hospital); Adakveo is prescribed by or in consultation with a physician who specializes in the treatment of sickle cell disease (e.g., a hematologist).
Adakveo is indicated to reduce the frequency of vaso-occlusive crises (VOCs) in adults and pediatric patients aged 16 years and older with sickle cell disease.
Indication: Crizanlizumab-tmca (Adakveo) is indicated for patients aged 16 years and older with sickle cell disease."
Indication for Adakveo (crizanlizumab-tmca): Patient has SCD with insufficient response to at least 3 months of hydroxyurea (or intolerance/contraindication) AND experienced two or more vaso-occlusive crises (VOC) in the prior year despite adherence to hydroxyurea therapy.

20 Active Policies

ARKBLUE-CRIZANLIZUMAB-E-G-ADAKVEO-BD08795C03, Crizanlizumab (e.g., Adakveo)

FLORIDA_BLUE-FLBLUE-CRIZANLIZUMAB-TMCA-ADAKVEO-FC6BC8DE96, Crizanlizumab-tmca (Adakveo)

BCBSLA-00704-4FB1FB841C, 00704 Novel Treatments for Sickle Cell Disease (Adakveo)

BCBSM-2117665-7247110E80, ADAKVEO (CRIZANLIZUMAB-TMCA)

BCBSMS-S-5-01-555-7C2ED4A9F8, State and School Employees' Health Insurance Plan - Adakveo (crizanlizumab-tmca)

BCBSMS-L-5-01-555-10E514B803, Adakveo (crizanlizumab-tmca)

HEALTHPARTNERS-CC-ENTRY-226968, Crizanlizumab-tmca (Adakveo)

MULTI

POINT32HEALTH-MDMNG-12191, Adakveo (crizanlizumab-tmca)

MULTI

BCBSND-CRIZANLIZUMAB-TMCA-ADAKVEO-E50F3C8ECD, Crizanlizumab Tmca Adakveo

BCBSNJ-DRUGS-198-09BF92D8E7, Crizanlizumab-tmca (Adakveo)

MODA-ADAKVEO-7765100610, Adakveo (crizanlizumab-tmca)

HEALTHNET_OR-HNOR-CRIZANLIZUMAB-TMCA-ADAKVEO-CP-PHAR-449-95427FC9FE, Crizanlizumab-tmca (Adakveo); CP.PHAR.449

IBX-MEDICARE-ADVANTAGE-MA08-109C-9ADA5F4D92, Crizanlizumab-tmca (Adakveo)

IBX-COMMERCIAL-08-00-04B-1BBC25B7A3, Crizanlizumab-tmca (Adakveo)

AMERIHEALTH-MEDICARE-ADVANTAGE-MA08-109C-B9DE59830A, Crizanlizumab-tmca (Adakveo)

BCBSTN-1146b033fb, Crizanlizumab-tmca(Adakveo)

EVICORE-MEDICAL_DRUG-76936323150D, Adakveo (crizanlizumab-tmca)

OSCAR-ADAKVEO-CRIZANLIZUMAB-PG193-VER-2-9CA2C2F2D2, Adakveo (crizanlizumab) (PG193, Ver. 2)

UHC-COMM-MD-ADAKVEO-CRIZANLIZUMAB-TMCA-COMMUNITY-PLA-2162BFC0F5, Adakveo (Crizanlizumab-Tmca) – Community Plan Medical Benefit Drug Policy

UHC-POL-adakveo-crizanlizumab-tmca, Adakveo (Crizanlizumab-Tmca)

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

Ask Backwork about J0791 Sign up free

`J0791`, Injection, crizanlizumab-tmca, 5 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J0791`, Injection, crizanlizumab-tmca, 5 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J0791, Injection, crizanlizumab-tmca, 5 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J0791, Injection, crizanlizumab-tmca, 5 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J0791`, Injection, crizanlizumab-tmca, 5 mg

`J0791`, Injection, crizanlizumab-tmca, 5 mg