Does J2597 require prior authorization?

Yes, J2597 requires prior authorization (medium confidence). Conditional coverage; review criteria to confirm PA need.

What is the Medicare reimbursement rate for J2597?

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

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`J2597`, Injection, desmopressin acetate, per 1 mcg

HCPCS/CPT

Prior Authorization

Prior Auth Required

Conditional coverage; review criteria to confirm PA need (medium confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

Use of appropriate diagnosis coding (policy references N39.44 - Nocturnal enuresis) and appropriate HCPCS (S8270 for enuresis alarm; J2597 for desmopressin injection) when selection criteria are met.
Clinical notes supporting diagnosis of primary nocturnal enuresis (e.g., absence of daytime symptoms) and linkage to ICD-10 code N39.44 when applicable.

For desmopressin, documentation that non-pharmacologic therapies were tried and failed (examples: fluid and food intake advice, enuresis alarm treatment) OR documentation that such therapies were refused or the patient is unlikely to adhere to them.

Key Coverage Criteria

Use of a bedwetting alarm as durable medical equipment for the treatment of primary nocturnal enuresis when ALL of the following criteria are met: member is 7 years of age or older; member has experienced bedwetting a minimum of 3 nights a week in the previous month, or at least 1 wetting episode weekly for 1 year; member has no daytime wetting; member has been examined by a physician, and physical or organic causes for nocturnal enuresis (e.g., renal disease, neurological disease, infection, et [...]
Desmopressin for the treatment of primary nocturnal enuresis in children older than 5 years whose bedwetting has not responded to non-pharmacologic therapies (e.g., fluid and food intake advice, enuresis alarm treatment), or when non-pharmacologic therapies were refused or the child is unlikely to adhere to enuresis alarm treatment.
HCPCS J2597 (injection, desmopressin acetate) — covered if selection criteria for desmopressin are met.
HCPCS S8270 (enuresis alarm, using auditory buzzer and/or vibration device) — covered if selection criteria for bedwetting alarm are met.
ICD-10 code N39.44 (Nocturnal enuresis) — listed as a covered diagnosis when selection criteria are met.

4 Active Policies

BCBSLA-00619-6EF9D88C15, 00619 desmopressin acetate (Nocdurna)

BCBSNE-X-121-21555031C3, NOCDURNA (desmopressin acetate) REQUIRES PRIOR AUTHORIZATION

HEALTHNET_OR-HNOR-DESMOPRESSIN-ACETATE-DDAVP-STIMATE-NOCDURNA-CP-PHAR-214-153A0BC9FB, Desmopressin Acetate (DDAVP, Stimate, Nocdurna); CP.PHAR.214

AETNA-CPB-0431, Enuresis

`J2597`, Injection, desmopressin acetate, per 1 mcg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

4 Active Policies

Related Codes

Have a follow-up question?

J2597, Injection, desmopressin acetate, per 1 mcg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

4 Active Policies

Related Codes

Have a follow-up question?

`J2597`, Injection, desmopressin acetate, per 1 mcg