Does N04.B1 require prior authorization?

No, N04.B1 does not require prior authorization (high confidence). Covered without prior authorization.

`N04.B1`, Nephrotic syndrome with idiopathic immune complex membranoproliferative glomerulonephritis (IC-MPGN)

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Document meningococcal immunization at least 2 weeks prior to the first eculizumab dose or a clinical justification that delaying eculizumab posed greater risk than meningococcal infection.
For PNH initiation, document flow cytometry confirming PNH and either evidence of clinically significant hemolysis or a documented history of a major adverse vascular event (MAVE) from thromboembolism.
For aHUS initial trial, document absence of signs of STEC-HUS and that TTP was ruled out (e.g., normal ADAMTS13 activity and no inhibitor), or document a plasma exchange trial that failed to produce clinical improvement.

Eculizumab is covered for treatment of paroxysmal nocturnal hemoglobinuria (PNH) when flow cytometry confirms PNH and there is either evidence of clinically significant hemolysis or a documented history of a major adverse vascular event (MAVE) from thromboembolism.
Eculizumab is covered for treatment of atypical hemolytic uremic syndrome (aHUS) as an initial trial (generally 6–12 weeks) when the individual has no signs of STEC-HUS and thrombotic thrombocytopenic purpura (TTP) has been ruled out or a trial of plasma exchange did not produce clinical improvement.
Eculizumab is covered for biopsy-proven dense deposit disease when elevated serum sC5b-9 (sMAC) levels are documented.
Eculizumab may be covered for other label and off-label indications supported by recognized compendia or the FDA label when dose and frequency conform to FDA labeling or recognized compendia guidance.
No specific clinical indications are listed in this article; follow the Local Coverage Determination (LCD) L39400 for indications for magnesium testing or services.
NGS covers leuprolide acetate (LHRH analog) as palliative treatment of advanced breast carcinoma in premenopausal and perimenopausal women.

NGS-J6-L33394, Drugs and Biologicals, Coverage of, for Label and Off-Label Uses

A54548, Billing and Coding: Eculizumab, and Biosimilars: EPYSQLI-eculizumab-aagh, and BKEMV-eculizumab-aeeb

NGS-JK-L33394, Drugs and Biologicals, Coverage of, for Label and Off-Label Uses

A59186, Billing and Coding: Magnesium