Does J2760 require prior authorization?

No, J2760 does not require prior authorization (high confidence). Covered without prior authorization.

What is the Medicare reimbursement rate for J2760?

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

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`J2760`, Injection, phentolamine mesylate, up to 5 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

Clinical documentation must support a clinical diagnosis of CRPS using the Budapest Criteria: continuing pain disproportionate to any inciting event; at least one reported symptom in each of the four categories (sensory, vasomotor, sudomotor/edema, motor/trophic); at least one sign at time of evaluation in two or more of these categories; and no other diagnosis that better explains the signs and symptoms.

History and physical exam records documenting the specific symptoms and signs required by the Budapest Criteria (sensory: hyperesthesia/allodynia; vasomotor: temperature asymmetry/skin color changes; sudomotor/oedema: edema/sweating changes; motor/trophic: decreased ROM, motor dysfunction, trophic changes).

If imaging or laboratory tests are used to exclude alternative diagnoses, documentation should show rationale for the test and how results influenced management; documentation should also show that the provider understands that listed experimental/investigational tests are not established diagnostic tools for CRPS.

When denying or not performing tests listed as investigational, documentation should record that the clinician is using accepted clinical criteria (Budapest) and provide justification for any additional testing performed to rule out alternative causes.

Key Coverage Criteria

Imaging or other studies may be used as additional/ supportive tools to establish the diagnosis in doubtful cases (clinical findings remain the gold standard).
Diagnosis of complex regional pain syndrome (CRPS), formerly known as reflex sympathetic dystrophy (RSD), is primarily a clinical diagnosis based on history and physical examination.
The Budapest Criteria (Harden et al.) are the preferred diagnostic tool for adults and should be used to make the clinical diagnosis of CRPS.
All individuals with suspected CRPS should undergo rapid diagnostic assessment by a clinician using clinical history and physical exam guided by the Budapest Criteria.
Medically necessary treatment for sexual dysfunction may be covered if the member's contract does not exclude sexual dysfunction services and the patient has a documented disease process (e.g., diabetes mellitus, hypertension, lipid abnormalities, or peripheral vascular disease).

5 Active Policies

AETNA-CPB-0147, Complex Regional Pain Syndrome (CRPS): Diagnosis

BCBSIL-MED201.030, Sexual Dysfunctions, Assessment and Treatment

BCBSMT-MED201.030, Sexual Dysfunctions, Assessment and Treatment

BCBSNM-MED201.030, Sexual Dysfunctions, Assessment and Treatment

BCBSOK-MED201.030, Sexual Dysfunctions, Assessment and Treatment

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J2760, Injection, phentolamine mesylate, up to 5 mg