Does J1553 require prior authorization?

Yes, J1553 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for J1553?

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

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`J1553`, Injection, immune globulin (yimmugo), 100 mg

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

Claims missing required NOC narrative information or with incorrect unit reporting will be rejected as unprocessable and may show remark code M123.
All documentation must be maintained in the patient's medical record, be legible, include complete patient identification and dates of service, and be produced upon contractor request.
Medical records must include the legible signature of the physician or non-physician practitioner responsible for the care.
The submitted medical record must support the ICD-10-CM code(s), the CPT/HCPCS code(s) billed, and the medical necessity of services as stated in the applicable NCD and LCD.
Records should include relevant diagnostic laboratory studies, prior history of bleeding or infection, disease progression, prior medical/surgical therapies, vaccination response, and any other information essential to establish that the patient meets NCD/LCD coverage indications.
Accurate patient weight in kilograms must be documented prior to infusion because immune globulin dosing is mg/kg based.

Key Coverage Criteria

Billing and coding guidance in this article applies when immune globulin use meets the reasonable and necessary coverage criteria established in LCD L35093.
Coverage requires documentation that the immune globulin therapy is reasonable and necessary in accordance with LCD L34007 and applicable NCDs.
IVIG is covered when the product is eligible under a Medicare benefit category, is reasonable and necessary for diagnosis or treatment per Social Security Act §1862(a)(1)(A), and meets all other applicable Medicare statutory and regulatory requirements and related LCD/Policy Article rules.
IVIG may be covered only when dispensed and billed to Medicare by the same entity that actually dispenses the drug to the Medicare beneficiary and that entity is licensed to dispense drugs in the state where it is physically located.
This policy addresses only the determination of medical necessity for the hospital outpatient setting for infusion and injectable therapy; the medical necessity of the pharmacologic or biologic medication itself may be reviewed separately.
Requests for select medications intended for administration in a hospital outpatient setting will be directed to a preferred alternative site of care (non-hospital affiliated outpatient facility or home).

20 Active Policies

A57778, Billing and Coding: Immune Globulin

FIRST_COAST-L34007, Immune Globulin

NORIDIAN-JE-L34314, Immune Globulin Intravenous (IVIg)

NORIDIAN-JF-L34314, Immune Globulin Intravenous (IVIg)

NOVITAS-JH-L35093, Immune Globulin

NOVITAS-JL-L35093, Immune Globulin

A56786, Billing and Coding: Immune Globulin

MODA-INTRAVENOUSIMMUNEGLOBULINS-F9839170DD, IVIG (immune globulin IV): Asceniv; Alyglo; Bivigam; Flebogamma; Gamunex-C; Gammagard Liquid; Gammagard S/D; Gammagard Liquid ERC; Gammaked; Gammaplex; Octagam; Privigen; Panzyga; Yimmugo

BCBSMT-RX504.003, Immunoglobulin Therapy

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

BCBSNM-RX504.003, Immunoglobulin Therapy

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

BCBSOK-RX504.003, Immunoglobulin Therapy

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

UMR-POL-UMR-immune-globulin-ivig-scig, Immune Globulin (IVIG and SCIG)

SUREST-POL-SUREST-immune-globulin-ivig-scig, Immune Globulin (IVIG and SCIG)

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

BCBSIL-RX504.003, Immunoglobulin Therapy

UHC-POL-immune-globulin-ivig-scig, Immune Globulin (IVIG and SCIG)

L33610, Intravenous Immune Globulin

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

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J1553, Injection, immune globulin (yimmugo), 100 mg

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

Claims missing required NOC narrative information or with incorrect unit reporting will be rejected as unprocessable and may show remark code M123.
All documentation must be maintained in the patient's medical record, be legible, include complete patient identification and dates of service, and be produced upon contractor request.
Medical records must include the legible signature of the physician or non-physician practitioner responsible for the care.
The submitted medical record must support the ICD-10-CM code(s), the CPT/HCPCS code(s) billed, and the medical necessity of services as stated in the applicable NCD and LCD.
Records should include relevant diagnostic laboratory studies, prior history of bleeding or infection, disease progression, prior medical/surgical therapies, vaccination response, and any other information essential to establish that the patient meets NCD/LCD coverage indications.
Accurate patient weight in kilograms must be documented prior to infusion because immune globulin dosing is mg/kg based.

Key Coverage Criteria

Billing and coding guidance in this article applies when immune globulin use meets the reasonable and necessary coverage criteria established in LCD L35093.
Coverage requires documentation that the immune globulin therapy is reasonable and necessary in accordance with LCD L34007 and applicable NCDs.
IVIG is covered when the product is eligible under a Medicare benefit category, is reasonable and necessary for diagnosis or treatment per Social Security Act §1862(a)(1)(A), and meets all other applicable Medicare statutory and regulatory requirements and related LCD/Policy Article rules.
IVIG may be covered only when dispensed and billed to Medicare by the same entity that actually dispenses the drug to the Medicare beneficiary and that entity is licensed to dispense drugs in the state where it is physically located.
This policy addresses only the determination of medical necessity for the hospital outpatient setting for infusion and injectable therapy; the medical necessity of the pharmacologic or biologic medication itself may be reviewed separately.
Requests for select medications intended for administration in a hospital outpatient setting will be directed to a preferred alternative site of care (non-hospital affiliated outpatient facility or home).

20 Active Policies

A57778, Billing and Coding: Immune Globulin

FIRST_COAST-L34007, Immune Globulin

NORIDIAN-JE-L34314, Immune Globulin Intravenous (IVIg)

NORIDIAN-JF-L34314, Immune Globulin Intravenous (IVIg)

NOVITAS-JH-L35093, Immune Globulin

NOVITAS-JL-L35093, Immune Globulin

A56786, Billing and Coding: Immune Globulin

BCBSMT-RX504.003, Immunoglobulin Therapy

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

BCBSNM-RX504.003, Immunoglobulin Therapy

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

BCBSOK-RX504.003, Immunoglobulin Therapy

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

UMR-POL-UMR-immune-globulin-ivig-scig, Immune Globulin (IVIG and SCIG)

SUREST-POL-SUREST-immune-globulin-ivig-scig, Immune Globulin (IVIG and SCIG)

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

BCBSIL-RX504.003, Immunoglobulin Therapy

UHC-POL-immune-globulin-ivig-scig, Immune Globulin (IVIG and SCIG)

L33610, Intravenous Immune Globulin

Have a follow-up question?

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

Ask Backwork about J1553 Sign up free

`J1553`, Injection, immune globulin (yimmugo), 100 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J1553`, Injection, immune globulin (yimmugo), 100 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J1553, Injection, immune globulin (yimmugo), 100 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J1553, Injection, immune globulin (yimmugo), 100 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J1553`, Injection, immune globulin (yimmugo), 100 mg

`J1553`, Injection, immune globulin (yimmugo), 100 mg