Does J1555 require prior authorization?

Yes, J1555 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for J1555?

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

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`J1555`, Injection, immune globulin (cuvitru), 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.
Covered when hospital outpatient facility infusion services for specialty medications and IVIG/SCIG therapy are considered medically necessary and the member meets the specific clinical criteria described in the policy.
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).
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.

20 Active Policies

FIRST_COAST-L34007, Immune Globulin

A57778, Billing and Coding: Immune Globulin

NOVITAS-JH-L35093, Immune Globulin

A56786, Billing and Coding: Immune Globulin

NOVITAS-JL-L35093, Immune Globulin

BCBSNJ-DRUGS-045-EEF5008B75, Immune Globulin Subcutaneous (Hizentra, Gammagard Liquid, Gamunex-C/Gammaked, HyQvia, Cuvitru, Cutaquig, and Xembify for Subcutaneous Administration)

MODA-SCIG-IMMUNEGLOBULINSQ-361D2FC801, SCIG (immune globulin SQ): Hizentra, Gammagard Liquid, Gamunex-C, Gammaked, HyQvia, Cuvitru, Cutaquig, Xembify

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

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)

UMR-POL-UMR-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care

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

BCBSIL-RX504.003, Immunoglobulin Therapy

UHC-POL-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care

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

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J1555, Injection, immune globulin (cuvitru), 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.
Covered when hospital outpatient facility infusion services for specialty medications and IVIG/SCIG therapy are considered medically necessary and the member meets the specific clinical criteria described in the policy.
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).
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.

20 Active Policies

FIRST_COAST-L34007, Immune Globulin

A57778, Billing and Coding: Immune Globulin

NOVITAS-JH-L35093, Immune Globulin

A56786, Billing and Coding: Immune Globulin

NOVITAS-JL-L35093, Immune Globulin

BCBSNJ-DRUGS-045-EEF5008B75, Immune Globulin Subcutaneous (Hizentra, Gammagard Liquid, Gamunex-C/Gammaked, HyQvia, Cuvitru, Cutaquig, and Xembify for Subcutaneous Administration)

MODA-SCIG-IMMUNEGLOBULINSQ-361D2FC801, SCIG (immune globulin SQ): Hizentra, Gammagard Liquid, Gamunex-C, Gammaked, HyQvia, Cuvitru, Cutaquig, Xembify

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

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)

UMR-POL-UMR-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care

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

BCBSIL-RX504.003, Immunoglobulin Therapy

UHC-POL-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care

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

Have a follow-up question?

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

Ask Backwork about J1555 Sign up free

`J1555`, Injection, immune globulin (cuvitru), 100 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J1555`, Injection, immune globulin (cuvitru), 100 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J1555, Injection, immune globulin (cuvitru), 100 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J1555, Injection, immune globulin (cuvitru), 100 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J1555`, Injection, immune globulin (cuvitru), 100 mg

`J1555`, Injection, immune globulin (cuvitru), 100 mg