Does J2404 require prior authorization?

No, J2404 does not require prior authorization (high confidence). Covered without prior authorization.

What is the Medicare reimbursement rate for J2404?

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

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`J2404`, Injection, nicardipine, 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

Diagnosis documentation of post-herpetic neuralgia (PHN) — clinical diagnosis typically from 'typical unilateral dermatomal pain and rash' and PHN defined in background as 'significant pain or dysaesthesia present 3 months or more following HZ.'
When billing CPT/HCPCS codes listed as 'covered if selection criteria are met,' documentation must demonstrate that the applicable selection criteria are met (policy: 'CPT codes / HCPCS codes / ICD-10 codes — CPT codes covered if selection criteria are met').

For use of Qutenza (capsaicin 8% patch): documentation that the patch was applied by a health care professional, the most painful skin areas treated, number of patches used (up to 4), duration of application (60 minutes), and monitoring for at least 1 hour post-application due to blood pressure risk ('Qutenza must be applied to the skin by a health care professional... The patient must also be monitored for at least 1 hour...').

When using injection/infusion HCPCS/J-codes listed in the policy (e.g., J1020, J1030, J1040, J1094, J1100, etc.), document the specific agent, dose, route and medical necessity for PHN treatment.

Use appropriate ICD-10 diagnosis codes (policy lists B02.21 - B02.29) on claims and in the medical record when indicated.

No documentation requirements, required medical records, test results, or clinical documentation are specified in this document chunk.

Key Coverage Criteria

Post-herpetic neuralgia (PHN).
Aetna considers the use of antivirals (oral), gabapentin, intrathecal, interlaminar or transforaminal epidural corticosteroids, lidocaine patch, opioids (oral), pregabalin, and tricyclic anti-depressants medically necessary for post-herpetic neuralgia (PHN).
CPT/HCPCS codes listed in the policy are covered if selection criteria are met (see 'CPT Codes / HCPCS Codes / ICD-10 Codes' section).
ICD-10 codes B02.21 - B02.29 (Zoster [herpes zoster] with other nervous system involvement) are listed as covered diagnoses if selection criteria are met.
Inferred: Postherpetic neuralgia (PHN) — multiple citations focus on treatment and prevention of PHN.
Inferred: Acute herpes zoster (shingles) and zoster-related pain — citations include trials and prevention strategies.

1 Active Policy

AETNA-CPB-0725, Post-Herpetic Neuralgia

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J2404, Injection, nicardipine, 0.1 mg