Does J1826 require prior authorization?

No, J1826 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 J1826?

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

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`J1826`, Injection, interferon beta-1a, 30 mcg

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

Imaging and laboratory/biomarker data used in studies: brain CT or MRI, amyloid PET (e.g., florbetapir), cerebrospinal fluid (CSF) biomarkers (Aβ1-42, total tau, phospho-tau), and APOE ε4 genotyping when reported in trials.
For some interventional procedures/trials, pre-procedure evaluations included medical/neurological and psychological examinations, depression rating scales (e.g., Montgomery–Asberg Depression Rating Scale), and lumbar puncture with CSF analysis.

Documentation of prior/concurrent standard therapies (e.g., use of cholinesterase inhibitors and/or memantine) is often recorded in trials and may be relevant when considering investigational add-on therapies.

None specified in this policy document. (The CPB lists investigational/experimental treatments and codes not covered; it does not define separate documentation requirements for coverage of the listed items.)

None specified in this document excerpt.

Diagnosis documentation: 'Diagnosis is usually made after a detailed medical history has been taken, infectious or dermatological abnormalities has been ruled out, and pain is elicited in response to light pressure on the labia, introitus, or hymenal remnants.' (policy background text).

Key Coverage Criteria

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:
Alzheimer's disease (AD)
mild cognitive impairment (MCI)
amnestic MCI
pre-clinical AD

3 Active Policies

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

AETNA-CPB-0759, Vulvodynia and Vulvar Vestibulitis Treatments

CIGNA-0328, Scar Revision

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J1826, Injection, interferon beta-1a, 30 mcg