Does J2150 require prior authorization?

No, J2150 does not require prior authorization (high confidence). Covered without prior authorization.

`J2150`, Injection, mannitol, 25% in 50 ml

HCPCS/CPT

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation the member is not scheduled to undergo total knee replacement within 6 months of starting treatment.
Radiographic evidence of osteoarthritis of the knee (e.g., joint space narrowing, subchondral sclerosis, osteophytes and sub-chondral cysts) OR documentation that member has at least 5 of the specified signs/symptoms (bony enlargement; bony tenderness; crepitus on active motion; ESR < 40 mm/hr; < 30 minutes morning stiffness; no palpable warmth of synovium; age > 50; rheumatoid factor < 1:40 titer (agglutination method); synovial fluid clear with normal viscosity and WBC < 2000/mm3).
Documentation that knee pain interferes with functional activities (e.g., ambulation, prolonged standing).
Documentation of inadequate response or adverse effects with non-pharmacologic treatment options (e.g., physical therapy, regular exercise, insoles, knee bracing, weight reduction).

Bony enlargement
Over 50 years of age
Rheumatoid factor less than 1:40 titer (agglutination method)
Synovial fluid signs (clear fluid of normal viscosity and WBC less than 2000/mm3)
The member has knee pain which interferes with functional activities (e.g., ambulation, prolonged standing)
The member has experienced an inadequate response or adverse effects with non-pharmacologic treatment options (e.g., physical therapy, regular exercise, insoles, knee bracing, weight reduction)

AETNA-CPB-0179, Viscosupplementation

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