Does J9216 require prior authorization?

Yes, J9216 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for J9216?

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

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`J9216`, Injection, interferon, gamma 1-b, 3 million units

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

Diagnosis documentation: 'Diagnosis is usually made after a detailed medical history has been taken, infectious or dermatological abnormalities has been ruled out, and pain is elicited in response to light pressure on the labia, introitus, or hymenal remnants.' (policy background text).

Demonstration of pain localization/testing: cotton swab test (cotton-swab test) for differentiating localized vulvodynia/vestibulitis and to outline areas of pain (policy background describes use of cotton swab test).

Evidence of failure of conservative measures prior to vestibulectomy: documentation that conservative measures were tried and failed, including vulvar care, physical therapy, pharmacotherapy (including analgesics) — required for vestibulectomy to be medically necessary per policy: 'Vestibulectomy (local or total) for persons who have failed conservative measures (including vulvar care, physical therapy, pharmacotherapy including analgesics).'

When billing: use of CPT/HCPCS codes only when selection/coverage criteria are met; do not submit CPT/HCPCS codes listed in the policy as 'CPT codes not covered for indications listed in the CPB' or HCPCS/J-codes listed as not covered for these indications.

For interventional or experimental procedures (laser, ESWT, LI-SWT, radiofrequency, neuromodulation, nerve blocks): documentation of investigational status, informed consent detailing risks/uncertainty and prior therapies tried, treatment protocol parameters, and follow-up pain/function assessments

Key Coverage Criteria

Members with vulvodynia/vulvar vestibulitis
Physical therapy (medically necessary for members with vulvodynia/vulvar vestibulitis)
Perineoplasty (medically necessary for members with vulvodynia/vulvar vestibulitis)
Vestibulectomy (local or total) for persons who have failed conservative measures (including vulvar care, physical therapy, pharmacotherapy including analgesics).
CPT codes covered if selection criteria are met: 56620-56640 (Vulvectomy range), 56810 (Perineoplasty, repair of perineum, nonobstetrical), 97010-97032, 97034-97039 (Physical medicine and rehabilitation modalities), 97110-97139 (Physical medicine and rehabilitation therapeutic procedures).
ICD-10 codes covered if selection criteria are met: N94.810 - N94.819 (Vulvodynia [vulvodynia and vulvar vestibulitis])

2 Active Policies

EVICORE-HPLAN-CIGNA-729A536F50C8, Q3 - 2026 Cigna MedOnc Master Drug List.pdf

AETNA-CPB-0759, Vulvodynia and Vulvar Vestibulitis Treatments

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J9216, Injection, interferon, gamma 1-b, 3 million units