Does J2325 require prior authorization?

No, J2325 does not require prior authorization (high confidence). Covered without prior authorization.

What is the Medicare reimbursement rate for J2325?

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

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`J2325`, Injection, nesiritide, 0.1 mg

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

Appropriate ICD-10 diagnosis code corresponding to an allowed covered acute HF diagnosis (see covered ICD-10 codes I50.21, I50.23, I50.31, I50.33, I50.41, I50.43) documented on the medical record and claim.
Documentation of contraindications screened (e.g., systolic blood pressure < 90 mm Hg, cardiogenic shock, hypersensitivity history) as relevant to safe use.

For billing: unit documentation consistent with HCPCS J2325 (nesiritide 0.1 mg) and use of appropriate infusion CPT codes (96365/96366/96367/96368/96379 as applicable) — and documentation supporting why 96372 (subcutaneous/intramuscular injection) is not appropriate (policy lists 96372 as not covered).

Documented diagnosis of acutely decompensated congestive heart failure (CHF) with dyspnea at rest or with minimal activity (medical record notes, ED/hospital admission documentation).

Clinical evidence supporting acute decompensation (e.g., signs/symptoms of fluid overload, elevated BNP where available, hemodynamic data if obtained).

Documentation of prior and/or concurrent use of standard therapies (attempts with vasodilators and/or diuretics) and rationale for nesiritide (policy recommends attempting other vasodilators/diuretics prior to nesiritide).

Key Coverage Criteria

Policy text: "The best candidates for nesiritide therapy are patients with decompensated HF who have clinical evidence of fluid over-load and/or raised central venous pressure [Quality of evidence: Low]."
Aetna considers nesiritide (Natrecor) medically necessary for the acute management of members with acutely decompensated congestive heart failure (CHF) who have dyspnea at rest or with minimal activity.
FDA-approved indication: intravenous treatment of patients with acutely decompensated heart failure who have dyspnea at rest or with minimal activity.
ICD-10 codes covered if selection criteria are met: I50.21 (Acute systolic (congestive) heart failure), I50.23 (Acute on chronic systolic (congestive) heart failure), I50.31 (Acute diastolic (congestive) heart failure), I50.33 (Acute on chronic diastolic (congestive) heart failure), I50.41 (Acute combined systolic (congestive) and diastolic (congestive) heart failure), I50.43 (Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure).
Guidance note (clinical preference): best candidates are patients with decompensated HF who have clinical evidence of fluid over-load and/or raised central venous pressure (noted under 'If nesiritide is used, take into consideration the following').

1 Active Policy

AETNA-CPB-0709, Nesiritide (Natrecor)

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J2325, Injection, nesiritide, 0.1 mg