Does J0802 require prior authorization?

Yes, J0802 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for J0802?

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

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`J0802`, Injection, corticotropin (ani), 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

Provider attestation that the caregiver is not able to be trained or is physically unable to administer the drug; provider must submit explanation; and

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.

11 Active Policies

BCBSM-2157724-2E92D843FE, CORTROPHIN GEL (REPOSITORY CORTICOTROPHIN)

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

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

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

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

EVICORE-MEDICAL_DRUG-92E2A2E2F0C5, Purified Cortrophin Gel (repository corticotropin injection)

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

UMR-POL-UMR-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)

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

`J0802`, Injection, corticotropin (ani), up to 40 units

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

11 Active Policies

Related Codes

Have a follow-up question?

J0802, Injection, corticotropin (ani), up to 40 units

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

11 Active Policies

Related Codes

Have a follow-up question?

`J0802`, Injection, corticotropin (ani), up to 40 units