CurrentUnitedHealthcarePolicy CSOH2025D0037.C

Repository Corticotropin Injections (for Ohio Only)

Medical benefit drug policy governing coverage and medical necessity review for repository corticotropin injections for UnitedHealthcare members in Ohio; applies to requests evaluated under Ohio Administrative Code when services are unproven or subject to limits.

Policy Summary

PayerUnitedHealthcare

PolicyRepository Corticotropin Injections (for Ohio Only)

Policy CodePolicy CSOH2025D0037.C

Change TypeHCPCS codes added and removed (operational)

Effective DateJun 1, 2025

Next Review Date

Key ActionSubmit prior authorization requests with documentation to demonstrate InterQual CP: Specialty Rx Non-Oncology criteria are met for Acthar Gel or Purified Cortrophin Gel.

SourceLink

POLICY UPDATE CHANGES

Added HCPCS codes J0801 and J0802 to Applicable Codes.

Removed HCPCS code J0800 from Applicable Codes.

2drug products referenced

2HCPCS codes listed

Ohio-onlystate applicability

InterQualclinical criteria source

Coverage and Medical Necessity

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Medical necessity (per InterQual)

Covered when InterQual CP: Specialty Rx Non-Oncology repository corticotropins criteria are met

InterQual-based coverage: Member meets the specific clinical criteria in the current InterQual CP: Specialty Rx Non-Oncology repository corticotropins for the requested indication for Acthar Gel or Purified Cortrophin Gel.

Apply Ohio Administrative Code and contractual requirements as applicable.

Listing of a code in this policy does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by federal, state, or contractual requirements and applicable laws and may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment; other policies and guidelines may apply.

Requests for services that are stated as unproven or services for which there is a coverage or quantity limit will be evaluated for medical necessity using Ohio Administrative Code 5160-1-01. Failure to meet those requirements may result in denial under the applicable state medical necessity rules.

Provider Requirements and Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for repository corticotropins (Acthar Gel, Purified Cortrophin Gel). Coverage is subject to review using the current InterQual® CP: Specialty Rx Non‑Oncology, Repository Corticotropins criteria. Submit prior authorization requests to UnitedHealthcare per payer-specific operational channels and include clinical documentation supporting InterQual criteria.

Affected products: Acthar® Gel; Purified Cortrophin® Gel
Use current release of InterQual® CP: Specialty Rx Non‑Oncology, Repository Corticotropins
Prior authorization must be obtained before drug administration

Denial Risk

Denial Triggers

Requests are likely to be denied when documentation does not meet InterQual® medical necessity criteria or when the requested use is considered unproven or not covered under Ohio Administrative Code 5160‑1‑01. Examples of denial triggers include: indication not supported by InterQual criteria, missing or insufficient clinical documentation, dosing outside recommended ranges, or lack of prior authorization.

Indication not meeting InterQual® criteria
Absence of required prior authorization
Incomplete clinical record to justify medical necessity
Requested dosing or frequency inconsistent with InterQual® guidance

Documentation Required

Documentation to Support Medical Necessity

Provide complete clinical documentation to support medical necessity and InterQual® criteria matching. Include diagnosis, prior therapies and responses, relevant laboratory and imaging results, treatment rationale, proposed dose/regimen, and treatment history. Retain and submit supporting records on request to avoid delays or denials.

Required documentation: diagnosis, clinical notes, prior treatment history, lab/imaging results
Specify prior therapies tried and clinical response or contraindications
Document proposed dose, duration, and monitoring plan
Reference InterQual® criteria lines that support the request

Step Therapy

No step therapy rules are specified in this policy; medical necessity determinations for initiation and continuation of repository corticotropins will follow the InterQual® CP criteria and applicable federal/state/contractual requirements.

No UnitedHealthcare step therapy requirements stated in this policy
Decisions are made using InterQual® CP: Specialty Rx Non‑Oncology, Repository Corticotropins

Definitions and Clinical Sources

InterQual criteria source

InterQual clinical criteria sourceInterQual CP: Specialty Rx Non-Oncology, Repository Corticotropins

Referenced drug productsActhar Gel (repository corticotropin injection); Purified Cortrophin Gel (repository corticotropin injection USP)

Use for medical necessity determinationsMedical necessity clinical coverage criteria are determined by the current release of the InterQual CP: Specialty Rx Non-Oncology, Repository Corticotropins

Access to criteriaRefer to the current release of InterQual CP: Specialty Rx Non-Oncology, Repository Corticotropins for specific covered indications and clinical requirements

Policy Summary

PayerUnitedHealthcare

PolicyRepository Corticotropin Injections (for Ohio Only)

Policy CodePolicy CSOH2025D0037.C

Change TypeHCPCS codes added and removed (operational)

Effective DateJun 1, 2025

Next Review Date

Key ActionSubmit prior authorization requests with documentation to demonstrate InterQual CP: Specialty Rx Non-Oncology criteria are met for Acthar Gel or Purified Cortrophin Gel.

SourceLink

On This Page

OpenPayer

Repository Corticotropin Injections (for Ohio Only)

Coverage and Medical Necessity

Applicable Codes

Provider Requirements and Authorization

Initial Therapy

Site-of-Care Considerations

Clinical Background

Definitions and Clinical Sources

J0801	Injection, corticotropin (acthar gel), up to 40 units.
J0802	Injection, corticotropin (ani), up to 40 units