Does S9346 require prior authorization?

No, S9346 does not require prior authorization (high confidence). Covered without prior authorization.

What is the Medicare reimbursement rate for S9346?

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

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`S9346`, Home infusion therapy, alpha-1-proteinase inhibitor (e.g., prolastin);

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

Documented pretreatment serum AAT level < 11 micromol/L (80 mg/dL by radial immunodiffusion or 50 mg/dL by nephelometry).
Documented pretreatment post-bronchodilation FEV1 value ≥ 25% and ≤ 80% of predicted (forced expiratory volume in 1 second, post-bronchodilation).

Documented AAT genotype/phenotype: PiZZ, PiZ (null), or Pi (null, null) (homozygous) AAT deficiency or other phenotype/genotype associated with serum AAT < 11 micromol/L.

For Aralast NP, Glassia, or Zemaira requests, documentation of contraindication, intolerance, or an ineffective trial to Prolastin-C (per brand selection requirement).

Key Coverage Criteria

Aetna considers alpha 1-proteinase inhibitor (e.g., Aralast NP, Glassia, Prolastin-C, and Zemaira) therapy medically necessary for the treatment of emphysema due to alpha 1-antitrypsin (AAT) deficiency when all of the following criteria are met:
The member’s pretreatment serum AAT level is less than 11 micromol/L (80 mg/dL by radial immunodiffusion or 50 mg/dL by nephelometry);
The member’s pretreatment post-bronchodilation forced expiratory volume in 1 second (FEV1) is greater than or equal to 25% and less than or equal to 80% of the predicted value;
The member has a documented PiZZ, PiZ (null), or Pi (null, null) (homozygous) AAT deficiency or other phenotype or genotype associated with serum AAT concentrations of less than 11 micromol/L (80 mg/dL by radial immunodiffusion or 50 mg/dL by nephelometry);
The member does not have the PiMZ or PiMS AAT deficiency.
Continuation: Aetna considers continuation of alpha 1-proteinase inhibitor (Aralast NP, Glassia, Prolastin-C, and Zemaira) therapy medically necessary for treatment of emphysema due to alpha 1-antitrypsin (AAT) deficiency when the member is experiencing beneficial clinical response from therapy.

2 Active Policies

ANTHEM-CG-MED-23, Home Health

AETNA-CPB-0145, Alpha1-Proteinase Inhibitors

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S9346, Home infusion therapy, alpha-1-proteinase inhibitor (e.g., prolastin);