Does J1100 require prior authorization?

No, J1100 does not require prior authorization (high confidence). Covered without prior authorization.

What is the Medicare reimbursement rate for J1100?

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

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`J1100`, Injection, dexamethasone sodium phosphate, 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

ISA candidates in trials had symptomatic medial compartment OA and had failed 6 months or more of conservative therapy ("received an ISA for symptomatic medial knee OA after failing 6 months or more of conservative therapy").
Arthroscopic meniscal procedures in some studies were performed after non-operative management and in populations characterized by tear type (traumatic vs degenerative) and by age (e.g., 18 to 55 or middle-aged 45 to 60 in cohort studies) — documentation of prior conservative care and tear characterization was part of enrollment criteria in multiple studies.

For percutaneous calcium phosphate injection trials, exclusions included mechanical axis deviation measurement (>8°) and MRI documentation of flipped displaced non-degenerative meniscal tear at level of BME lesions (these imaging/measurement data were required to determine eligibility in the study).

Radiographic confirmation of knee OA (Kellgren-Lawrence (KL) grade II/III) as used in the cited clinical studies.

Documentation of symptom severity such as baseline and follow-up pain scores (Numeric Rating Scale, NRS 0-10) and functional scores (e.g., WOMAC) as used in trials (baseline, before/after treatment, and at end of treatment period).

Record of prior conservative therapies attempted (for example, physical therapy, topical NSAIDs) and whether patient failed to respond to PT when SAM is being considered as an adjunct.

Key Coverage Criteria

Arthroscopic debridement (with or without partial meniscectomy) for persons presenting with mild-to-moderate (Outerbridge classification I and II, not III or IV) osteoarthritis (OA) with knee pain plus mechanical symptoms due to loose bodies and/or meniscal tears;
Arthroscopic partial meniscectomy for traumatic meniscal tears unless there is moderate or severe osteoarthritis present (Outerbridge classification III or IV);
Intra-articular glucocorticoid injections for the treatment of knee OA.
CPT/HCPCS/ICD-10 codes listed as "covered if selection criteria are met": e.g., CPT 29874 (Arthroscopy, knee, surgical; for removal of loose body or foreign body), G0289, CPTs 29880/29881 for arthroscopic partial meniscectomy, ICD-10 M17.0–M17.9 (Osteoarthritis of knee), M23.000–M23.369 (Derangement of meniscus due to old tear or injury), M25.561–M25.569 (Pain in knee), M25.661–M25.669 (Stiffness of knee), Q68.6 (Discoid meniscus) — when the CPB selection criteria are met.
Moderate-to-severe knee pain with radiographically confirmed knee OA (Kellgren-Lawrence (KL) grade II/III).
cryoneurolysis of the IPBSN resulted in statistically significant decreased knee pain and improved symptoms compared to sham treatment for up to 150 days; and appeared safe and well-tolerated.

17 Active Policies

FIRST_COAST-L33912, Trigger Point Injections

FIRST_COAST-L40314, Trigger Point Injections

NOVITAS-JH-L35010, Trigger Point Injections

NOVITAS-JH-L40310, Trigger Point Injections

NOVITAS-JL-L40310, Trigger Point Injections

NOVITAS-JL-L35010, Trigger Point Injections

AETNA-CPB-0179, Viscosupplementation

AETNA-CPB-0422, Vitiligo

BCBSIL-MED205.039, Sphenopalatine Ganglion Block for Headache

BCBSMT-MED205.039, Sphenopalatine Ganglion Block for Headache

BCBSNM-MED205.039, Sphenopalatine Ganglion Block for Headache

BCBSOK-MED205.039, Sphenopalatine Ganglion Block for Headache

AETNA-CPB-0016, Back Pain - Invasive Procedures

AETNA-CPB-0462, Headaches: Nonsurgical Management

AETNA-CPB-0484, Glaucoma Surgery

AETNA-CPB-0673, Knee Arthroscopy / Osteoarthritis of the Knee

AETNA-CPB-0679, Levator Syndrome Treatments

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J1100, Injection, dexamethasone sodium phosphate, 1 mg