Does J1786 require prior authorization?

Yes, J1786 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for J1786?

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

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`J1786`, Injection, imiglucerase, 10 units

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

Documentation: beta-glucocerebrosidase enzyme assay or genetic testing results supporting diagnosis required for prior authorization.
Continuation of ERT requires documented positive clinical response, FDA-labeled dosing, and continuation up to 12 months.
Initial authorization duration limited to 12 months.
Documentation requirement: Prior authorization is valid initially for 12 months (365 days).

Key Coverage Criteria

Initial therapy for Type 1 Gaucher disease with Cerezyme, Elelyso, or VPRIV requires: (1) diagnosis of Type 1 Gaucher disease, (2) symptomatic disease, (3) dosing in accordance with FDA labeling, and (4) initial authorization for up to 12 months; continuation requires: (1) documented positive clinical response, (2) dosing in accordance with FDA labeling, and (3) continuation up to 12 months.
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.
Taliglucerase alfa (Elelyso) is covered for individuals ≥4 years with confirmed Type 1 Gaucher disease.
Velaglucerase alpha (VPRIV) is covered for long-term ERT in individuals ≥4 years with Type 1 Gaucher disease.
Vestronidase alfa-vjbk (Mepsevii) is covered for individuals with MPS VII (Sly syndrome).
Agalsidase beta (Fabrazyme) is covered when the member is ≥2 years old and has a confirmed diagnosis of Fabry disease.

20 Active Policies

ARKBLUE-TREATMENT-FOR-GAUCHER-DISEASE-IMIGLUCERASE-E-G-C-02A240C009, Treatment for Gaucher Disease: [Imiglucerase (e.g., Cerezyme), taliglucerase alfa (e.g., Elelyso), and velaglucerase alfa (e.g., Vpriv)]

BCBSM-2131764-594E44BDB1, CEREZYME (IMIGLUCERASE) ENZYME REPLACEMENT THERAPY (J1786) retired as of 10/8/2020

HEALTHPARTNERS-CC-AENTRY-046263, Gaucher disease enzyme replacement therapy: imiglucerase (Cerezyme), velaglucerase (Vpriv), and taliglucerase (Elelyso)

MULTI

POINT32HEALTH-MDMNG-22656, Cerezyme (imiglucerase), Elelyso (taliglucerase alfa), VPRIV velaglucerase alfa)

MULTI

HEALTHNET_OR-HNOR-IMIGLUCERASE-CEREZYME-CP-PHAR-154-68553EF2CD, Imiglucerase (Cerezyme); CP.PHAR.154

MODA-CEREZYME-664CC772A2, Cerezyme (imiglucerase)

BCBSNM-RX501.067, Enzyme-Replacement Therapy for Lysosomal Storage Disorders

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

BCBSOK-RX501.067, Enzyme-Replacement Therapy for Lysosomal Storage Disorders

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

UHC-POL-intravenous-enzyme-replacement-therapy-gaucher-disease, Intravenous Enzyme Replacement Therapy (ERT) for Gaucher Disease

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

SUREST-POL-SUREST-intravenous-enzyme-replacement-therapy-gaucher-disease, Intravenous Enzyme Replacement Therapy (ERT) for Gaucher Disease

BCBSTN-80396eeac3, Imiglucerase (Cerezyme)

EVICORE-MEDICAL_DRUG-F0080DDB713F, Cerezyme (imiglucerase)

UMR-POL-UMR-intravenous-enzyme-replacement-therapy-gaucher-disease, Intravenous Enzyme Replacement Therapy (ERT) for Gaucher Disease

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

BCBSIL-RX501.067, Enzyme-Replacement Therapy for Lysosomal Storage Disorders

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

BCBSMT-RX501.067, Enzyme-Replacement Therapy for Lysosomal Storage Disorders

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J1786, Injection, imiglucerase, 10 units

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

Documentation: beta-glucocerebrosidase enzyme assay or genetic testing results supporting diagnosis required for prior authorization.
Continuation of ERT requires documented positive clinical response, FDA-labeled dosing, and continuation up to 12 months.
Initial authorization duration limited to 12 months.
Documentation requirement: Prior authorization is valid initially for 12 months (365 days).

Key Coverage Criteria

Initial therapy for Type 1 Gaucher disease with Cerezyme, Elelyso, or VPRIV requires: (1) diagnosis of Type 1 Gaucher disease, (2) symptomatic disease, (3) dosing in accordance with FDA labeling, and (4) initial authorization for up to 12 months; continuation requires: (1) documented positive clinical response, (2) dosing in accordance with FDA labeling, and (3) continuation up to 12 months.
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.
Taliglucerase alfa (Elelyso) is covered for individuals ≥4 years with confirmed Type 1 Gaucher disease.
Velaglucerase alpha (VPRIV) is covered for long-term ERT in individuals ≥4 years with Type 1 Gaucher disease.
Vestronidase alfa-vjbk (Mepsevii) is covered for individuals with MPS VII (Sly syndrome).
Agalsidase beta (Fabrazyme) is covered when the member is ≥2 years old and has a confirmed diagnosis of Fabry disease.

20 Active Policies

BCBSM-2131764-594E44BDB1, CEREZYME (IMIGLUCERASE) ENZYME REPLACEMENT THERAPY (J1786) retired as of 10/8/2020

HEALTHPARTNERS-CC-AENTRY-046263, Gaucher disease enzyme replacement therapy: imiglucerase (Cerezyme), velaglucerase (Vpriv), and taliglucerase (Elelyso)

MULTI

POINT32HEALTH-MDMNG-22656, Cerezyme (imiglucerase), Elelyso (taliglucerase alfa), VPRIV velaglucerase alfa)

MULTI

HEALTHNET_OR-HNOR-IMIGLUCERASE-CEREZYME-CP-PHAR-154-68553EF2CD, Imiglucerase (Cerezyme); CP.PHAR.154

MODA-CEREZYME-664CC772A2, Cerezyme (imiglucerase)

BCBSNM-RX501.067, Enzyme-Replacement Therapy for Lysosomal Storage Disorders

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

BCBSOK-RX501.067, Enzyme-Replacement Therapy for Lysosomal Storage Disorders

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

UHC-POL-intravenous-enzyme-replacement-therapy-gaucher-disease, Intravenous Enzyme Replacement Therapy (ERT) for Gaucher Disease

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

SUREST-POL-SUREST-intravenous-enzyme-replacement-therapy-gaucher-disease, Intravenous Enzyme Replacement Therapy (ERT) for Gaucher Disease

BCBSTN-80396eeac3, Imiglucerase (Cerezyme)

EVICORE-MEDICAL_DRUG-F0080DDB713F, Cerezyme (imiglucerase)

UMR-POL-UMR-intravenous-enzyme-replacement-therapy-gaucher-disease, Intravenous Enzyme Replacement Therapy (ERT) for Gaucher Disease

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

BCBSIL-RX501.067, Enzyme-Replacement Therapy for Lysosomal Storage Disorders

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

BCBSMT-RX501.067, Enzyme-Replacement Therapy for Lysosomal Storage Disorders

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

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`J1786`, Injection, imiglucerase, 10 units

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J1786`, Injection, imiglucerase, 10 units

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J1786, Injection, imiglucerase, 10 units

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J1786, Injection, imiglucerase, 10 units

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J1786`, Injection, imiglucerase, 10 units

`J1786`, Injection, imiglucerase, 10 units