Does J1572 require prior authorization?

No, J1572 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 J1572?

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

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`J1572`, Injection, immune globulin, (flebogamma/flebogamma dif), intravenous,

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

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.
IVIG is covered only for indications specified as covered in the related Local Coverage Determination (LCD) and when medical necessity criteria in that LCD are met.
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.
None specified. This Clinical Policy Bulletin addresses experimental treatments for Alzheimer's disease and lists treatments considered experimental and investigational (i.e., not established as effective) for this indication.
No explicit covered indications are stated in this document. The document discusses potential therapeutic use in the following conditions:

20 Active Policies

CGS-J15-L38268, Immune Thrombocytopenia (ITP) Therapy

J15

CGS-J15-L35891, Intravenous Immune Globulin

J15

CGS-J18-L38268, Immune Thrombocytopenia (ITP) Therapy

J18

CGS-J18-L35891, Intravenous Immune Globulin

J18

A57554, Billing and Coding: Immune Globulins

WPS-J5-L34771, Immune Globulins

WPS-J8-L34771, Immune Globulins

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

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

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

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

AETNA-CPB-0648, Autism Spectrum Disorders

BCBSIL-RX504.003, Immunoglobulin Therapy

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

BCBSMT-RX504.003, Immunoglobulin Therapy

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

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J1572, Injection, immune globulin, (flebogamma/flebogamma dif), intravenous,

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

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.
IVIG is covered only for indications specified as covered in the related Local Coverage Determination (LCD) and when medical necessity criteria in that LCD are met.
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.
None specified. This Clinical Policy Bulletin addresses experimental treatments for Alzheimer's disease and lists treatments considered experimental and investigational (i.e., not established as effective) for this indication.
No explicit covered indications are stated in this document. The document discusses potential therapeutic use in the following conditions:

20 Active Policies

CGS-J15-L38268, Immune Thrombocytopenia (ITP) Therapy

J15

CGS-J15-L35891, Intravenous Immune Globulin

J15

CGS-J18-L38268, Immune Thrombocytopenia (ITP) Therapy

J18

CGS-J18-L35891, Intravenous Immune Globulin

J18

A57554, Billing and Coding: Immune Globulins

WPS-J5-L34771, Immune Globulins

WPS-J8-L34771, Immune Globulins

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

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

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

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

AETNA-CPB-0648, Autism Spectrum Disorders

BCBSIL-RX504.003, Immunoglobulin Therapy

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

BCBSMT-RX504.003, Immunoglobulin Therapy

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

Have a follow-up question?

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

Ask Backwork about J1572 Sign up free

`J1572`, Injection, immune globulin, (flebogamma/flebogamma dif), intravenous,

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J1572`, Injection, immune globulin, (flebogamma/flebogamma dif), intravenous,

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J1572, Injection, immune globulin, (flebogamma/flebogamma dif), intravenous,

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J1572, Injection, immune globulin, (flebogamma/flebogamma dif), intravenous,

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J1572`, Injection, immune globulin, (flebogamma/flebogamma dif), intravenous,

`J1572`, Injection, immune globulin, (flebogamma/flebogamma dif), intravenous,