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ACTH Gel (Repository Corticotropin Injection)
Effective date
Not stated in the notice
Identified
Jun 20, 2026
Summary
Repository corticotropin injection may be considered medically necessary for the treatment of infantile spasms (West syndrome). It is considered investigational for diagnostic testing of adrenocortical function, for corticosteroid-responsive conditions unless there are medical contraindications or intolerance to corticosteroids that are not also expected with this injection, and for conditions not responsive to corticosteroid therapy, including tobacco cessation, acute gout and childhood epilepsy. The most recent policy history entry, dated 01/10/2025, states the policy was reviewed with no changes.
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What to do
Action · 3 steps
01Billing team: Perform a formulary drug search on the member ID to confirm the prescription drug is covered under the member's benefit plan, since the medication may not be covered under a specific member's benefit plan.
02Billing team: For use in corticosteroid-responsive conditions, the record must document medical contraindications or intolerance to corticosteroids that are not also expected to occur with this injection, since otherwise the use is considered investigational.
03Billing team: For Federal Employee Program members, the policy notes that FEP may dictate that FDA-approved drugs may not be considered investigational and may be assessed only on the basis of medical necessity.
Codes mentioned
96372G40.821G40.824
Original notice
ACTH Gel (Repository Corticotropin Injection)
bcbsms.com · Always check the source before changing claims.
Related changes
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