Does J1436 require prior authorization?

No, J1436 does not require prior authorization (high confidence). Covered without prior authorization.

What is the Medicare reimbursement rate for J1436?

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

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`J1436`, Injection, etidronate disodium, per 300 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

Functional outcome measures: pre- and post-operative scores such as Modified Harris Hip Score (MHHS) and Visual Analog Scale (VAS) (used to document clinical improvement in studies).
Detailed documentation of BMAC/BMDCT procedures: harvest technique, preparation method, cellular characterization/quality of the BMAC (authors note inconsistent reporting and recommend following consensus guidelines).

Procedure-specific details for adjuvants: if intraosseous ibandronate used, document technique, dose/administration and safety monitoring (Kumar et al. 2021 reported technique and safety in their small series).

For procedures using bone marrow–derived products: detailed documentation of BMAC / BMDCT preparation and harvest (cell counts/characteristics) — the literature notes inconsistent reporting and recommends following consensus guidelines.

Key Coverage Criteria

“When bilateral core decompression is indicated, it can be done simultaneously on both hips...”
Aetna considers core decompression medically necessary for the treatment of early/pre-collapse (stage I or II; before X-ray changes are evident) avascular necrosis of the hip (femoral head and/or neck).
HCPCS code S2325 (Hip core decompression) — covered if selection criteria are met.
Core decompression (CD) for management of pre-collapse stage of ONFH.
Adjunctive approaches for early (pre-collapse) femoral head osteonecrosis that are repeatedly discussed as treatment options (with varying evidence): "core decompression combined with bone grafting", "core decompression and implantation of autologous BMMC/BMSCs/bone marrow cells", "core decompression combined with PRP/PRF/platelet concentrates", "core decompression with synthetic bone graft substitute (calcium sulfate and calcium phosphate)", "core decompression combined with bone morphogenetic [...]
Pre-collapse stage of osteonecrosis of the femoral head (ONFH)

`J1436`, Injection, etidronate disodium, per 300 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

1 Active Policy

Related Codes

Have a follow-up question?

J1436, Injection, etidronate disodium, per 300 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

1 Active Policy

Related Codes

Have a follow-up question?

`J1436`, Injection, etidronate disodium, per 300 mg