Does J1745 require prior authorization?

Yes, J1745 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for J1745?

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

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`J1745`, Injection, infliximab, excludes biosimilar, 10 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

Medical records must document the basis for each diagnosis and that diagnoses follow recognized standards (eg, American College of Rheumatology guidelines).
Medical records must include patient weight when needed to determine appropriate dosing.
Medical records must document evaluation for latent tuberculosis infection with a medical evaluation and TB test, and initiation of latent TB treatment prior to infliximab when indicated.
Medical records must document disease‑specific relevant symptoms and signs that are being treated and monitored to assess response to treatment.
For biologic initiation, documentation must show inadequate response (lack of efficacy, adverse effects, or contraindication) to a 3‑month trial of appropriately dosed, disease‑specific conventional (non‑biologic) therapy.
For plaque psoriasis, documentation should include percent body surface area affected, PASI score, PDI score, or other psoriasis assessment tools and documentation of planned close follow‑up; monitor for nonmelanoma skin cancer especially after prior prolonged phototherapy.

Key Coverage Criteria

Infliximab and its FDA‑approved biosimilars are covered when administered in accordance with the FDA‑approved label or recognized compendia for labeled and off‑label uses.
Covered for Crohn's disease when medical records document disease‑specific signs/symptoms (eg, abdominal pain, diarrhea, fistulae) and dosing per label or compendia; retreatment is covered if prior initial treatment produced reduction in clinical signs and symptoms.
Covered for rheumatoid arthritis when prescribed per label/compendia and medical record documents concomitant methotrexate use or a documented contraindication to methotrexate.
Covered for plaque psoriasis when documentation shows chronic, severe, extensive, or disabling disease (eg, percent BSA, PASI, or PDI) and the patient will have close physician follow‑up and monitoring.
Claims for pyoderma gangrenosum with coexisting inflammatory bowel disease are covered when the claim includes both primary and secondary ICD‑10‑CM diagnosis codes documenting pyoderma gangrenosum and IBD.
NGS covers leuprolide acetate (LHRH analog) as palliative treatment of advanced breast carcinoma in premenopausal and perimenopausal women.

20 Active Policies

ARKBLUE-MEASUREMENT-OF-SERUM-ANTIBODIES-TO-INFLIXIMAB-AD-67B2805EB5, Measurement of Serum Antibodies to Infliximab, Adalimumab, Vedolizumab, and Ustekinumab

ARKBLUE-INFLIXIMAB-E-G-REMICADE-AND-UNBRANDED-INFLIXIMAB-D15A87E98B, Infliximab (e.g., Remicade and Unbranded Infliximab) and Biosimilars

FLORIDA_BLUE-FLBLUE-INFLIXIMAB-C0B4FFD8EA, Infliximab

BCIDAHO-02-04-084-B40CEF1360, Measurement of Serum Antibodies to Selected Biologic Agents. Codes Number Description CPT 80145 Adalimumab 80230 Infliximab 80280 Vedolizumab 82397 Chemiluminescent assay 83520

BCIDAHO-05-01-668-98991347DF, Intravenous Infliximab. Medical Policy MP 5.01.668 Intravenous Infliximab DISCLAIMER/INSTRUCTIONS FOR USE This medical policy provides general guidance for applying Blue Cross of Idaho benefit

A52423, Billing and Coding: Infliximab and biosimilars

NGS-J6-L33394, Drugs and Biologicals, Coverage of, for Label and Off-Label Uses

PALMETTO-JJ-L35677, Infliximab

NGS-JK-L33394, Drugs and Biologicals, Coverage of, for Label and Off-Label Uses

PALMETTO-JM-L35677, Infliximab

BCBSLA-00217-54DD244C8E, 00217 Select infliximab Products

BCBSLA-00712-70F56030FD, 00712 infliximab-axxq (Avsola)- Retired Policy

BCBSLA-00607-8D981262D7, 00607 infliximab-abda (Renflexis)- Retired Policy

BCBSLA-00897-7EEAC08B5A, 00897 infliximab-dyyb (Zymfentra)

BCBSLA-00331-7BCA2636DE, 00331 Measurement of Serum Antibodies to Infliximab and Adalimumab-Retired Policy

BCBSLA-00539-0B603F2F81, 00539 infliximab-dyyb (Inflectra)-Retired Policy

BCBSM-2067530-D841B8AA72, INFLIXIMAB POLICY

CLOVER-PARTB-7109, Specialty Exceptions Autoimmune-Infliximab Med B-Med B ABF 5290-D P2026

MULTI

POINT32HEALTH-PMNG-24656, Zymfentra (infliximab-dyyb) Subcutaneous

MULTI

BCBSND-INFLIXIMAB-DFBA761C80, Infliximab

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J1745, Injection, infliximab, excludes biosimilar, 10 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

Medical records must document the basis for each diagnosis and that diagnoses follow recognized standards (eg, American College of Rheumatology guidelines).
Medical records must include patient weight when needed to determine appropriate dosing.
Medical records must document evaluation for latent tuberculosis infection with a medical evaluation and TB test, and initiation of latent TB treatment prior to infliximab when indicated.
Medical records must document disease‑specific relevant symptoms and signs that are being treated and monitored to assess response to treatment.
For biologic initiation, documentation must show inadequate response (lack of efficacy, adverse effects, or contraindication) to a 3‑month trial of appropriately dosed, disease‑specific conventional (non‑biologic) therapy.
For plaque psoriasis, documentation should include percent body surface area affected, PASI score, PDI score, or other psoriasis assessment tools and documentation of planned close follow‑up; monitor for nonmelanoma skin cancer especially after prior prolonged phototherapy.

Key Coverage Criteria

Infliximab and its FDA‑approved biosimilars are covered when administered in accordance with the FDA‑approved label or recognized compendia for labeled and off‑label uses.
Covered for Crohn's disease when medical records document disease‑specific signs/symptoms (eg, abdominal pain, diarrhea, fistulae) and dosing per label or compendia; retreatment is covered if prior initial treatment produced reduction in clinical signs and symptoms.
Covered for rheumatoid arthritis when prescribed per label/compendia and medical record documents concomitant methotrexate use or a documented contraindication to methotrexate.
Covered for plaque psoriasis when documentation shows chronic, severe, extensive, or disabling disease (eg, percent BSA, PASI, or PDI) and the patient will have close physician follow‑up and monitoring.
Claims for pyoderma gangrenosum with coexisting inflammatory bowel disease are covered when the claim includes both primary and secondary ICD‑10‑CM diagnosis codes documenting pyoderma gangrenosum and IBD.
NGS covers leuprolide acetate (LHRH analog) as palliative treatment of advanced breast carcinoma in premenopausal and perimenopausal women.

20 Active Policies

ARKBLUE-MEASUREMENT-OF-SERUM-ANTIBODIES-TO-INFLIXIMAB-AD-67B2805EB5, Measurement of Serum Antibodies to Infliximab, Adalimumab, Vedolizumab, and Ustekinumab

ARKBLUE-INFLIXIMAB-E-G-REMICADE-AND-UNBRANDED-INFLIXIMAB-D15A87E98B, Infliximab (e.g., Remicade and Unbranded Infliximab) and Biosimilars

FLORIDA_BLUE-FLBLUE-INFLIXIMAB-C0B4FFD8EA, Infliximab

A52423, Billing and Coding: Infliximab and biosimilars

NGS-J6-L33394, Drugs and Biologicals, Coverage of, for Label and Off-Label Uses

PALMETTO-JJ-L35677, Infliximab

NGS-JK-L33394, Drugs and Biologicals, Coverage of, for Label and Off-Label Uses

PALMETTO-JM-L35677, Infliximab

BCBSLA-00217-54DD244C8E, 00217 Select infliximab Products

BCBSLA-00712-70F56030FD, 00712 infliximab-axxq (Avsola)- Retired Policy

BCBSLA-00607-8D981262D7, 00607 infliximab-abda (Renflexis)- Retired Policy

BCBSLA-00897-7EEAC08B5A, 00897 infliximab-dyyb (Zymfentra)

BCBSLA-00331-7BCA2636DE, 00331 Measurement of Serum Antibodies to Infliximab and Adalimumab-Retired Policy

BCBSLA-00539-0B603F2F81, 00539 infliximab-dyyb (Inflectra)-Retired Policy

BCBSM-2067530-D841B8AA72, INFLIXIMAB POLICY

CLOVER-PARTB-7109, Specialty Exceptions Autoimmune-Infliximab Med B-Med B ABF 5290-D P2026

MULTI

POINT32HEALTH-PMNG-24656, Zymfentra (infliximab-dyyb) Subcutaneous

MULTI

BCBSND-INFLIXIMAB-DFBA761C80, Infliximab

Have a follow-up question?

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

Ask Backwork about J1745 Sign up free

`J1745`, Injection, infliximab, excludes biosimilar, 10 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J1745`, Injection, infliximab, excludes biosimilar, 10 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J1745, Injection, infliximab, excludes biosimilar, 10 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J1745, Injection, infliximab, excludes biosimilar, 10 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J1745`, Injection, infliximab, excludes biosimilar, 10 mg

`J1745`, Injection, infliximab, excludes biosimilar, 10 mg