Does J1438 require prior authorization?

No, J1438 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

What is the Medicare reimbursement rate for J1438?

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

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`J1438`, Injection, etanercept, 25 mg (code may be used for medicare when drug

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Covered without prior authorization by at least one policy, though another does not cover it (medium confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

For some systemic or investigational therapy trials, baseline and end-of-study laboratory tests were obtained: "Blood samples for measurements of complete blood count along with thyroid function (T3, T4 and TSH) and liver function tests were taken at the baseline and at the end of study." (triiodothyronine trial)

Trial protocols and observational studies commonly documented: duration of current episode, baseline percent scalp hair loss, prior treatments and response, and follow-up visit schedules (e.g., "Subjects were reviewed every 3 months for 2 years", "Patients were followed-up for 3 months", "Patients received 4 to 8 sessions repeated at an interval of 3 to 4 weeks").

For intralesional corticosteroid therapy: documentation of treated patches and number/timing of monthly injections ("Multiple injections are administered monthly...an average of 4 to 6 monthly injections are usually required").

When topical immunotherapy used, documentation of treatment duration and response timing required: "Initial responses are generally seen after 12 weeks of therapy...cosmetically acceptable results in 24 weeks...If there is no response by the end of 24 weeks, immunotherapy is discontinued."

Key Coverage Criteria

Extensive alopecia areata (involving more than 50 % loss of scalp hair) — treatments may include topical immunotherapy, systemic agents or other measures: "Therapy for extensive alopecia areata (involving more than 50 % loss of scalp hair) may be prolonged and difficult...Systemic corticosteroids are seldom used due to their adverse effects; however, they may be required depending on the severity of the condition and the adequacy of the response to topical therapy."
Topical immunotherapy (DPCP/DCP and SADBE) for scalp hair loss of 50 to 99 % — "Topical immunotherapy...with reported hair growth rates of 40 to 60 % among patients with scalp hair loss of 50 to 99 %."
Psoralen photochemotherapy (PUVA) as an option for alopecia areata (used in practice by AAD despite limited evidence) — "Psoralen photochemotherapy (psoralen and ultraviolet light A or PUVA) is another immunosuppressant treatment that is used for alopecia areata...Despite these limitations, PUVA is still considered standard practice of care by the American Academy of Dermatology."
Topical 5% minoxidil for patchy alopecia areata — meta-analysis finding: "The meta-analysis involving 5% minoxidil versus placebo presented a significant difference in favor of 5% minoxidil...in children and adults with patchy AA."
Intralesional corticosteroids (monthly injections) for localized patches — "Multiple injections are administered monthly to the skin in and around the bare patches; an average of 4 to 6 monthly injections are usually required for significant improvement."
Excimer laser (308-nm) for patchy scalp alopecia areata — several small studies and meta-analyses: "In a few small studies and case reports, treatment with the excimer laser was associated with improvement in patchy alopecia areata of the scalp."

7 Active Policies

AETNA-CPB-0423, Alopecia Areata

AETNA-CPB-0788, Alzheimer's Disease: Experimental, Investigational, or Unproven Treatments

AETNA-CPB-0389, Hypertrophic Scars and Keloids

AETNA-CPB-0457, Dry Eyes

AETNA-CPB-0602, Intradiscal Procedures

AETNA-CPB-0422, Vitiligo

CIGNA-0328, Scar Revision

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J1438, Injection, etanercept, 25 mg (code may be used for medicare when drug