CurrentEmblemHealthPolicy MG.MM.PH.320

Medical Policy: Barhemsys (amisulpride)

Defines medical necessity criteria, dosing, limitations, coding (J-code, NDCs, ICD-10), authorization length, and maximum units for Barhemsys (amisulpride) when used for prevention or treatment of PONV in adult patients.

Policy Summary

PayerEmblemHealth

PolicyMedical Policy: Barhemsys (amisulpride)

Policy CodePolicy MG.MM.PH.320

Change TypeAnnual review; coding updates

Effective DateFeb 25, 2025

Next Review Date

Key ActionTreating physician must submit clinical evidence that member meets criteria (age, timing of surgery) to EmblemHealth for preauthorization or post-payment review; without documentation EmblemHealth will not review the request.

SourceLink

POLICY UPDATE CHANGES

Annual Review: No criteria changes (2/25/2025).

4/2/2024: Removed codes C9153 and C9399, added J0184, updated NDCs.

9/11/2023: Removed JCode3490 Unclassified drugs. Added C9153 Injection, amisulpride, 1 mg.

Policy originated 11/11/2020.

2Covered Indications

1 monthLength of Authorization

5 mg / 10 mgMax Single Doses (prevention / treatment)

Coverage Summary

Coverage stance: Covered with criteria for Barhemsys (amisulpride) for prevention and treatment of postoperative nausea and vomiting (PONV). Scope: defines medical necessity criteria, dosing, limitations, coding (J-code, NDCs, ICD-10), authorization length, and maximum units for adult patients. Status: CURRENT. Subject: Barhemsys (amisulpride) for PONV. Effective / Last review date: 2025-02-25.

Initial Therapy Criteria

Initial Approval Criteria

Barhemsys may be considered medically necessary if all of the below conditions are met AND use is consistent with the medical necessity criteria that follows:

Indication (ONE of)

Prevention of PONV
- Patient is 18 years of age or older>= 18 years
- Patient has a scheduled surgery within the next 30 daysscheduled within next 30 days
Treatment of PONV
- Patient is 18 years of age or older>= 18 years
- Patient has had a surgery within the last 30 dayshad surgery within last 30 days

ref

title': 'Initial Approval Criteria

Applicable Codes

Applicable HCPCS/J-codeHCPCSCovered

J0184

Injection, amisulpride, 1 mg

Applicable NDCsNDCCovered

71390-0125-XX	Barhemsys (amisulpride) injection, 5 mg in 2 mL
71390-0125-XX	Barhemsys (amisulpride) injection, 10 mg in 4 mL

Applicable ICD-10 Diagnoses (supported indications)ICD-10Covered

R11.0	Nausea
R11.10	Vomiting, unspecified
R11.12	Projectile vomiting
T41.0X5A	Adverse effect of inhaled anesthetics, initial encounter (nausea with vomiting, unspecified)
T41.1X5A	Adverse effect of intravenous anesthetics, initial encounter (nausea with vomiting, unspecified)
T41.2X5A	Adverse effect of unspecified general anesthetics, initial encounter (nausea with vomiting, unspecified)
T41.295A	Adverse effect of other general anesthetics, initial encounter (nausea with vomiting, unspecified)
T41.45XA	Adverse effect of unspecified anesthetic, initial encounter (nausea with vomiting, unspecified)
T88.59XA	Other complications of anesthesia, initial encounter (nausea with vomiting, unspecified)

Provider Actions

Prior Authorization

Documentation required for review

Treating physician must submit clinical evidence that member meets criteria (age, timing of surgery) to EmblemHealth for preauthorization or post-payment review; without documentation EmblemHealth will not review the request.

Billing Rule

Dose reporting via J-code

Report amisulpride using J0184 (injection, amisulpride, 1 mg) with units corresponding to mg administered.

J0184

Billing Rule

NDC reporting

Use listed NDC(s) for product identification: 71390-0125-XX.

71390-0125-XX

Clinical Evidence

Evidence: Barhemsys package insert, Acacia Pharma Inc., February 2020.

Background/mechanism and indication note: Barhemsys (amisulpride) is a selective dopamine-2 (D2) and dopamine-3 (D3) receptor antagonist with minimal affinity for other receptors; D2 receptors are located in the chemoreceptor trigger zone (CTZ) and activation relays stimuli to the vomiting center involved in emesis. It is indicated for prevention and treatment of postoperative nausea and vomiting and is administered intravenously.

Definitions

Barhemsys (amisulpride): A selective dopamine-2 (D2) and dopamine-3 (D3) receptor antagonist used to prevent and treat postoperative nausea and vomiting.

PONV: Postoperative nausea and vomiting.

Revision History

2025-02-25clarifiedLatest

Annual Review: No criteria changes (2/25/2025). Revision history notes no criteria changes at this review.

2024-04-02revised

Removed codes C9153 and C9399, added J0184, updated NDCs. Coding and NDC updates effective 4/2/2024.

2023-09-11revised

Removed JCode3490 Unclassified drugs. Added C9153 Injection, amisulpride, 1 mg. Coding updates.

2020-11-11added

Policy originated 11/11/2020. New policy creation.