Does J0801 require prior authorization?

Yes, J0801 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for J0801?

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

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`J0801`, Injection, corticotropin (acthar gel), up to 40 units

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

Precertification of repository corticotropin injection (Acthar Gel or Purified Cortrophin Gel) is required. For precertification of Acthar Gel or Purified Cortrophin Gel, call (866) 752-7021 or fax (888) 267-3277. For Statement of Medical Necessity (SMN) precertification forms, see Specialty Pharmacy Precertification.

Documentation that the patient is less than 2 years of age and has the diagnosis of infantile spasms (Epileptic spasms [West's syndrome]; ICD-10: G40.821 - G40.824) when requesting coverage for Acthar Gel.

If Purified Cortrophin Gel is being considered for other uses, the policy notes the manufacturer labeling recommendation that 'Standard tests for verification of adrenal responsiveness to corticotropin... Verification tests should be performed prior to treatment with corticotropins' — however Aetna considers corticotropin not medically necessary for diagnostic testing of adrenocortical function.

Standard tests for verification of adrenal responsiveness to corticotropin should be performed prior to treatment with corticotropins; the test should utilize the route(s) of administration proposed for treatment.

Key Coverage Criteria

Acthar Gel (repository corticotropin injection) and Purified Cortrophin Gel (repository corticotropin injection USP) are medically necessary for infantile spasms (West Syndrome) up to 4 weeks if: diagnosis of infantile spasms, patient <2 years, caregiver training/ability issue with explanation, dosing per FDA labeling, authorization up to 1 month; and for opsoclonus-myoclonus syndrome with diagnosis and caregiver training/ability issue with explanation, authorization up to 3 months.
Aetna considers repository corticotropin injection (Acthar Gel only) medically necessary for treatment of infantile spasms in members who are less than 2 years of age.
Continuation of repository corticotropin injection (Acthar Gel only) therapy is medically necessary for infantile spasms when the member has shown substantial clinical benefit from therapy.
HCPCS codes J0801 and J0802 covered if selection criteria are met (Injection, corticotropin (acthar gel), up to 40 units; Injection, corticotropin (ani), up to 40 units).
ICD-10 codes covered if selection criteria are met: G40.821 - G40.824 (Epileptic spasms [West's syndrome]) — [Acthar gel only].
Recommended dosage regimen for the treatment of acute exacerbations in adults with multiple sclerosis: The recommended dose is daily intramuscular or subcutaneous doses of 80-120 units for 2 to 3 weeks for acute exacerbations.

14 Active Policies

BCBSM-2027132-6A37C78D6B, H.P. ACTHAR GEL (REPOSITORY CORTICOTROPIN INJECTION)

BCBSND-REPOSITORY-CORTICOTROPIN-INTRAMUSCULAR-I-68F97487D1, Repository Corticotropin Intramuscular Injection Acthar GEL

BCBSNJ-DRUGS-048-D839695A68, H.P. Acthar Gel

MODA-ACTHAR-1CB123AB3A, Corticotropin-ACTH: Acthar Gel (repository corticotropin injection) Cortrophin Gel (repository corticotropin injection)

HEALTHNET_OR-HNOR-CORTICOTROPIN-H-P-ACTHAR-PURIFIED-CORTROPHIN-GEL-CP-PHAR-D0A7B25FF8, Corticotropin (H.P. Acthar, Purified Cortrophin Gel); CP.PHAR.168

IBX-COMMERCIAL-08-01-12E-4EC86DEEFB, Repository Corticotropin Injection (Acthar Gel, Purified Cortrophin Gel)

HIGHMARK_WHOLECARE-HMWC-MEDICAID-MEDICATIO-4AUE4FSALUGHG-ZMQUJ9OQ-A2D92AF4BC, Corticotropin (H.P. Acthar, Purified Cortrophin Gel)

AETNA-CPB-0762, Repository Corticotropin Injection (Acthar Gel and Purified Cortrophin Gel)

BCBSTN-3317627ff4, Corticotropin-ACTH: [HP Acthar Gel (repository corticotropin injection), Cortrophin Gel

EVICORE-MEDICAL_DRUG-CFA3B45BB5B0, Acthar Gel (repository corticotropin injection)

UHC-POL-repository-corticotropin-injection-hp-acthar-gel, Repository Corticotropin Injections

SUREST-POL-SUREST-repository-corticotropin-injection-hp-acthar-gel, Repository Corticotropin Injections

AMERIHEALTH-COMMERCIAL-08-01-12E-0634FDB941, Repository Corticotropin Injection (Acthar Gel, Purified Cortrophin Gel)

UMR-POL-UMR-repository-corticotropin-injection-hp-acthar-gel, Repository Corticotropin Injections

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J0801, Injection, corticotropin (acthar gel), up to 40 units