Does J9038 require prior authorization?

Yes, J9038 requires prior authorization (medium confidence). Conditional coverage; review criteria to confirm PA need.

What is the Medicare reimbursement rate for J9038?

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

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`J9038`, Injection, axatilimab-csfr, 0.1 mg

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

Documentation/authorization requirement: Authorization will be issued for no more than 12 months.

Key Coverage Criteria

Covered indication: Niktimvo (axatilimab-csfr) is medically necessary for treatment of chronic graft-versus-host disease (cGVHD) in patients who have failed at least two prior lines of systemic therapy and meet all initial-therapy criteria (diagnosis of cGVHD per NIH criteria, history of failure with corticosteroids and another specified agent, patient weight ≥40 kg, prescribed by/consulted with transplant specialist, dosing per FDA-labeled indication, and authorization for up to 12 months).

20 Active Policies

ARKBLUE-AXATILIMAB-E-G-NIKTIMVO-28C2A1BCB9, Axatilimab (e.g., Niktimvo)

BCBSLA-00935-C9D9AA6B84, 00935 axatilimab-csfr (Niktimvo)

BCBSM-2191170-E7990BE822, NIKTIMVO (AXATILIMAB-CSFR)

BCBSMS-L-5-01-623-A78832C77C, Niktimvo (axatilimab-csfr)

BCBSMS-S-5-01-623-57BBE8C428, State and School Employees' Health Insurance Plan - Niktimvo (axatilimab-csfr)

POINT32HEALTH-MDMNG-13321, Niktimvo (axatilimab-csfr)

MULTI

POINT32HEALTH-MDMNG-13331, Niktimvo (axatilimab-csfr)

MULTI

HEALTHPARTNERS-CC-ENTRY-285876, Axatilimab-csfr (Niktimvo)

MULTI

MODA-MODA-MPS-NIKTIMVO-142AFD3892, Niktimvo (axatilimab-csfr)

HEALTHNET_OR-HNOR-AXATILIMAB-CSFR-NIKTIMVO-CP-PHAR-691-2DA0878926, Axatilimab-csfr (Niktimvo); CP.PHAR.691

IBX-COMMERCIAL-08-02-34-45CF99826A, Axatilimab-csfr (Niktimvo) for Intravenous Use

IBX-MEDICARE-ADVANTAGE-MA08-180-2F5DA214D6, Axatilimab-csfr (Niktimvo) for Intravenous Use

SUREST-POL-SUREST-niktimvo, Niktimvo (Axatilimab-Csfr)

AMERIHEALTH-MEDICARE-ADVANTAGE-MA08-180-75FD5B2564, Axatilimab-csfr (Niktimvo) for Intravenous Use

BCBSTN-3c9ee51750, Axatilimab-csfr (Niktimvo)

OSCAR-NIKTIMVO-AXATILIMAB-PG252-VER-2-2DE7F99EFD, Niktimvo (axatilimab) (PG252, Ver. 2)

UHC-COMM-MD-NIKTIMVOTM-AXATILIMAB-CSFR-COMMUNITY-PLA-ABCD173767, Niktimvo (Axatilimab-Csfr) – Community Plan Medical Benefit Drug Policy

UHC-EXCH-MD-NIKTIMVOTM-AXATILIMAB-CSFR-COMMERCIAL-AN-3A2E470B8F, Niktimvo (Axatilimab-Csfr) – Commercial and Individual Exchange Medical Benefit Drug Policy

UHC-POL-niktimvo, Niktimvo (Axatilimab-Csfr)

UMR-POL-UMR-niktimvo, Niktimvo (Axatilimab-Csfr)

`J9038`, Injection, axatilimab-csfr, 0.1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J9038, Injection, axatilimab-csfr, 0.1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J9038`, Injection, axatilimab-csfr, 0.1 mg