Is Preauth Required?
Preauthorization is required for the use of Humira for rheumatoid arthritis.
Will the claim be denied?
Humira is an FDA approved drug for the treatment of rheumatoid arthritis, so a claim for it would not be denied.
When is the following treatment medically necessary for the condition specified?
Humira is considered medically necessary for the treatment of rheumatoid arthritis when the patient has had an inadequate response to one or more disease-modifying antirheumatic drugs (DMARDs) or when the patient has had an inadequate response or intolerance to methotrexate.
What would make the following treatment considered medically necessary?
Humira is considered medically necessary for the treatment of rheumatoid arthritis when other treatments, such as non-steroidal anti-inflammatory drugs, corticosteroids, or disease-modifying anti-rheumatic drugs (DMARDs), have not been effective.
What are the relevant codes for the treatment?
Group 1 Codes: Code: J1459 Description: Humira (adalimumab), per 10 mg Code: J1745 Description: Injection, adalimumab (Humira), 20 mg Code: J3490 Description: Unclassified drugs or biologics CPT/HCPCS Coding: No CPT/HCPCS codes are available for this treatment and condition.
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