Does J0885 require prior authorization?

Yes, J0885 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for J0885?

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

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`J0885`, Injection, epoetin alfa, (for non-esrd use), 1000 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

Medical record must document reasonable and necessary basis for ESA therapy, including that Hb/HCT values, dose and route of administration, and that ESA use is appropriate for the individualized patient.
Medical record must include most recent blood pressure and demonstrate reasonable control, weight in kilograms, date and results of Hb or HCT prior to ESA administration, and assessment that other causes of anemia are ruled out or managed.
Every page of the medical record must be legible with patient identification, dates of service, and the legible signature of the responsible physician or non-physician practitioner; submitted records must support the selected ICD-10-CM and CPT/HCPCS codes.
Non-ESRD claims for J0881, J0885 and Q5106 must include one of modifiers EA (chemo-induced), EB (radio-induced), or EC (non-chemo/radio); all applicable ESA claims must report exactly one route modifier: JA (IV), JB (subcutaneous), or JE (via dialysate).
Claims must report the most recent Hb or Hct reading on the claim: institutional claims use value code 48 (Hb) or 49 (HCT); professional paper claims place results in item 19 of CMS-1500; electronic 837P claims use Loop 2400 MEA with MEA01=TR, MEA02=R1 (Hb) or R2 (HCT), and MEA03=the test result.
Imaging evidence documenting a salvageable tissue penumbra (e.g., advanced imaging such as CT perfusion demonstrating salvageable tissue) when endovascular stent retriever therapy is being considered: 'evidence of salvageable tissue on imaging' (explicit requirement in medical necessity statement).

Key Coverage Criteria

ESA therapy is indicated for anemia due to decreased erythropoietin production or relative erythropoietin resistance, e.g., anemia of chronic renal failure or end-stage renal disease (ESRD).
ESA therapy is indicated to maintain hematologic targets with typical goals of hematocrit 30.0-36.0% (hemoglobin 10.0-12.0 g/dL) and the medical record should document rationale for dose changes or values outside these ranges.
ESA therapy may be considered for other chronic conditions not specifically addressed by this policy when the patient demonstrates considerable transfusion dependence and anemia-related symptoms and documentation supports reasonable and necessary use.
Intraarterial infusion of spasmolytics (e.g., papaverine) or calcium-channel blockers (e.g., nicardipine) into the intracranial arteries for the treatment of medically refractory symptomatic delayed cerebral ischemia (cerebral vasospasm) after aneurysmal subarachnoid hemorrhage.
CPT codes covered if selection criteria are met: 37184 (primary percutaneous transluminal mechanical thrombectomy, noncoronary, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic injection(s); initial vessel), 37185 (second and all subsequent vessel(s) within the same vascular family), and 61645 (percutaneous arterial transluminal mechanical thrombectomy and/or infusion for thrombolysis, intracranial, any method, including diagnost [...]
ICD-10 codes covered if selection criteria are met: I63.00 - I63.9 (cerebral infarction [acute ischemic stroke]); I67.82 (cerebral ischemia [medically refractory symptomatic delayed cerebral ischemia]); I67.841 - I67.848 (cerebral vasospasm and vasoconstriction [medically refractory symptomatic delayed cerebral ischemia]).

20 Active Policies

CGS-J15-L40386, Erythropoiesis Stimulating Agents (ESA)

J15

CGS-J15-L34356, Erythropoiesis Stimulating Agents (ESA)

J15

CGS-J18-L34356, Erythropoiesis Stimulating Agents (ESA)

J18

CGS-J18-L40386, Erythropoiesis Stimulating Agents (ESA)

J18

WPS-J5-L34633, Erythropoiesis Stimulating Agents (ESAs)

A56795, Billing and Coding: Erythropoiesis Stimulating Agents (ESAs)

NGS-J6-L40333, Erythropoiesis Stimulating Agents

NGS-J6-L40334, Erythropoiesis Stimulating Agents

WPS-J8-L34633, Erythropoiesis Stimulating Agents (ESAs)

PALMETTO-JJ-L39237, Erythropoiesis Stimulating Agents

NGS-JK-L40334, Erythropoiesis Stimulating Agents

NGS-JK-L40333, Erythropoiesis Stimulating Agents

PALMETTO-JM-L39237, Erythropoiesis Stimulating Agents

BCBSLA-00210-60A0AB5406, 00210 Erythropoiesis-Stimulating Agents (ESA’s): epoetin alfa (Epogen and Procrit), epoetin alfa-epbx (Retacrit), darbepoetin alfa (Aranesp), and pegylated epoetin beta (Mircera)

MODA-ESA-2188222DD4, Epoetin alfa: Epogen; Procrit; Retacrit

HEALTHNET_OR-HNOR-EPOETIN-ALFA-EPOGEN-PROCRIT-EPOETIN-ALFA-EPBX-RETACRIT-C-7FFD127D80, Epoetin Alfa (Epogen, Procrit), Epoetin alfa-epbx (Retacrit); CP.PHAR.237

AETNA-CPB-0789, Acute Ischemic Stroke Treatments

BCBSIL-RX501.069, Erythropoiesis-Stimulating Agents (ESAs)

BCBSIL-RX502.061, Oncology Medications

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

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J0885, Injection, epoetin alfa, (for non-esrd use), 1000 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

Medical record must document reasonable and necessary basis for ESA therapy, including that Hb/HCT values, dose and route of administration, and that ESA use is appropriate for the individualized patient.
Medical record must include most recent blood pressure and demonstrate reasonable control, weight in kilograms, date and results of Hb or HCT prior to ESA administration, and assessment that other causes of anemia are ruled out or managed.
Every page of the medical record must be legible with patient identification, dates of service, and the legible signature of the responsible physician or non-physician practitioner; submitted records must support the selected ICD-10-CM and CPT/HCPCS codes.
Non-ESRD claims for J0881, J0885 and Q5106 must include one of modifiers EA (chemo-induced), EB (radio-induced), or EC (non-chemo/radio); all applicable ESA claims must report exactly one route modifier: JA (IV), JB (subcutaneous), or JE (via dialysate).
Claims must report the most recent Hb or Hct reading on the claim: institutional claims use value code 48 (Hb) or 49 (HCT); professional paper claims place results in item 19 of CMS-1500; electronic 837P claims use Loop 2400 MEA with MEA01=TR, MEA02=R1 (Hb) or R2 (HCT), and MEA03=the test result.
Imaging evidence documenting a salvageable tissue penumbra (e.g., advanced imaging such as CT perfusion demonstrating salvageable tissue) when endovascular stent retriever therapy is being considered: 'evidence of salvageable tissue on imaging' (explicit requirement in medical necessity statement).

Key Coverage Criteria

ESA therapy is indicated for anemia due to decreased erythropoietin production or relative erythropoietin resistance, e.g., anemia of chronic renal failure or end-stage renal disease (ESRD).
ESA therapy is indicated to maintain hematologic targets with typical goals of hematocrit 30.0-36.0% (hemoglobin 10.0-12.0 g/dL) and the medical record should document rationale for dose changes or values outside these ranges.
ESA therapy may be considered for other chronic conditions not specifically addressed by this policy when the patient demonstrates considerable transfusion dependence and anemia-related symptoms and documentation supports reasonable and necessary use.
Intraarterial infusion of spasmolytics (e.g., papaverine) or calcium-channel blockers (e.g., nicardipine) into the intracranial arteries for the treatment of medically refractory symptomatic delayed cerebral ischemia (cerebral vasospasm) after aneurysmal subarachnoid hemorrhage.
CPT codes covered if selection criteria are met: 37184 (primary percutaneous transluminal mechanical thrombectomy, noncoronary, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic injection(s); initial vessel), 37185 (second and all subsequent vessel(s) within the same vascular family), and 61645 (percutaneous arterial transluminal mechanical thrombectomy and/or infusion for thrombolysis, intracranial, any method, including diagnost [...]
ICD-10 codes covered if selection criteria are met: I63.00 - I63.9 (cerebral infarction [acute ischemic stroke]); I67.82 (cerebral ischemia [medically refractory symptomatic delayed cerebral ischemia]); I67.841 - I67.848 (cerebral vasospasm and vasoconstriction [medically refractory symptomatic delayed cerebral ischemia]).

20 Active Policies

CGS-J15-L40386, Erythropoiesis Stimulating Agents (ESA)

J15

CGS-J15-L34356, Erythropoiesis Stimulating Agents (ESA)

J15

CGS-J18-L34356, Erythropoiesis Stimulating Agents (ESA)

J18

CGS-J18-L40386, Erythropoiesis Stimulating Agents (ESA)

J18

WPS-J5-L34633, Erythropoiesis Stimulating Agents (ESAs)

A56795, Billing and Coding: Erythropoiesis Stimulating Agents (ESAs)

NGS-J6-L40333, Erythropoiesis Stimulating Agents

NGS-J6-L40334, Erythropoiesis Stimulating Agents

WPS-J8-L34633, Erythropoiesis Stimulating Agents (ESAs)

PALMETTO-JJ-L39237, Erythropoiesis Stimulating Agents

NGS-JK-L40334, Erythropoiesis Stimulating Agents

NGS-JK-L40333, Erythropoiesis Stimulating Agents

PALMETTO-JM-L39237, Erythropoiesis Stimulating Agents

MODA-ESA-2188222DD4, Epoetin alfa: Epogen; Procrit; Retacrit

HEALTHNET_OR-HNOR-EPOETIN-ALFA-EPOGEN-PROCRIT-EPOETIN-ALFA-EPBX-RETACRIT-C-7FFD127D80, Epoetin Alfa (Epogen, Procrit), Epoetin alfa-epbx (Retacrit); CP.PHAR.237

AETNA-CPB-0789, Acute Ischemic Stroke Treatments

BCBSIL-RX501.069, Erythropoiesis-Stimulating Agents (ESAs)

BCBSIL-RX502.061, Oncology Medications

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

Have a follow-up question?

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

Ask Backwork about J0885 Sign up free

`J0885`, Injection, epoetin alfa, (for non-esrd use), 1000 units

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J0885`, Injection, epoetin alfa, (for non-esrd use), 1000 units

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J0885, Injection, epoetin alfa, (for non-esrd use), 1000 units

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J0885, Injection, epoetin alfa, (for non-esrd use), 1000 units

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J0885`, Injection, epoetin alfa, (for non-esrd use), 1000 units

`J0885`, Injection, epoetin alfa, (for non-esrd use), 1000 units