Does J3304 require prior authorization?

Yes, J3304 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for J3304?

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

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`J3304`, Injection, triamcinolone acetonide, preservative-free, extended-release,

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

ISA candidates in trials had symptomatic medial compartment OA and had failed 6 months or more of conservative therapy ("received an ISA for symptomatic medial knee OA after failing 6 months or more of conservative therapy").

Arthroscopic meniscal procedures in some studies were performed after non-operative management and in populations characterized by tear type (traumatic vs degenerative) and by age (e.g., 18 to 55 or middle-aged 45 to 60 in cohort studies) — documentation of prior conservative care and tear characterization was part of enrollment criteria in multiple studies.

For percutaneous calcium phosphate injection trials, exclusions included mechanical axis deviation measurement (>8°) and MRI documentation of flipped displaced non-degenerative meniscal tear at level of BME lesions (these imaging/measurement data were required to determine eligibility in the study).

Documentation of symptom severity such as baseline and follow-up pain scores (Numeric Rating Scale, NRS 0-10) and functional scores (e.g., WOMAC) as used in trials (baseline, before/after treatment, and at end of treatment period).

Record of prior conservative therapies attempted (for example, physical therapy, topical NSAIDs) and whether patient failed to respond to PT when SAM is being considered as an adjunct.

Key Coverage Criteria

Arthroscopic debridement (with or without partial meniscectomy) for persons presenting with mild-to-moderate (Outerbridge classification I and II, not III or IV) osteoarthritis (OA) with knee pain plus mechanical symptoms due to loose bodies and/or meniscal tears;
Arthroscopic partial meniscectomy for traumatic meniscal tears unless there is moderate or severe osteoarthritis present (Outerbridge classification III or IV);
Intra-articular glucocorticoid injections for the treatment of knee OA.
CPT/HCPCS/ICD-10 codes listed as "covered if selection criteria are met": e.g., CPT 29874 (Arthroscopy, knee, surgical; for removal of loose body or foreign body), G0289, CPTs 29880/29881 for arthroscopic partial meniscectomy, ICD-10 M17.0–M17.9 (Osteoarthritis of knee), M23.000–M23.369 (Derangement of meniscus due to old tear or injury), M25.561–M25.569 (Pain in knee), M25.661–M25.669 (Stiffness of knee), Q68.6 (Discoid meniscus) — when the CPB selection criteria are met.
Moderate-to-severe knee pain with radiographically confirmed knee OA (Kellgren-Lawrence (KL) grade II/III).
cryoneurolysis of the IPBSN resulted in statistically significant decreased knee pain and improved symptoms compared to sham treatment for up to 150 days; and appeared safe and well-tolerated.

14 Active Policies

ARKBLUE-TRIAMCINOLONE-ACETONIDE-EXTENDED-RELEASE-E-G-ZIL-BEC381379D, Triamcinolone Acetonide Extended Release (e.g., Zilretta)

FLORIDA_BLUE-FLBLUE-ZILRETTA-DFE7B2F422, Zilretta

BCBSLA-00612-B34FC2B736, 00612 triamcinolone extended release intra-articular injection (Zilretta)

BCBSM-2097415-B082042017, ZILRETTA (TRIAMCINOLONE ACETONICE)

BCBSNJ-DRUGS-181-B68D7DC6B6, Triamcinolone Acetonide Extended-Release (Zilretta)

MODA-ZILRETTA-FFAA27BC39, Zilretta (triamcinolone acetonide ER)

HEALTHNET_OR-HNOR-TRIAMCINOLONE-ER-INJECTION-ZILRETTA-CP-PHAR-371-EDC3A939C5, Triamcinolone ER Injection (Zilretta); CP.PHAR.371

IBX-MEDICARE-ADVANTAGE-MA08-097A-A45C552D63, Triamcinolone Acetonide ER Injectable (Zilretta)

IBX-COMMERCIAL-08-01-47A-4E8991AA19, Triamcinolone Acetonide Extended-Release Injectable (Zilretta)

AETNA-CPB-0016, Back Pain - Invasive Procedures

AMERIHEALTH-COMMERCIAL-08-01-47A-DEF643E980, Triamcinolone Acetonide Extended-Release Injectable (Zilretta)

AMERIHEALTH-MEDICARE-ADVANTAGE-MA08-097A-05074FC356, Triamcinolone Acetonide ER Injectable (Zilretta)

AETNA-CPB-0673, Knee Arthroscopy / Osteoarthritis of the Knee

EVICORE-MEDICAL_DRUG-1936CBCB97B2, Zilretta (triamcinolone acetonide extended-release injectable suspension)

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J3304, Injection, triamcinolone acetonide, preservative-free, extended-release,