Medical Policy

Effective Date:12/01/2012 Title:Factor Products for Bleeding Disorders
Revision Date:10/01/2019 Document:BI391:00
CPT Code(s):J7180-J7183, J7185-J7187, J7189, J7190, J7192, J7193-J7195, J7200-J7201, J7205, J7208, J7209 J7210, J7211
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    All Factor Products require prior authorization.

2)    Factor products are used to treat hemophilia A, hemophilia B, and von Willebrand disease, among other coagulation disorders.

3)    Factor products include Afstyla®, Adynovate, Alprolix®, Eloctate®, Novoseven®, Novoeight ®, Rixubis®, Monoclate-P®, Humate-P®, Alphanate®, Corifact™, Hemofil M®, Koate-DVI®, Wilate®, Advate®, Helixate FS®, Kogenate FS®, Kovaltry®, Recombinate®, Xyntha®, Mononine®, Alphanine SD®, Profilnine®, Tretten®, Bebuline VH®, Benefix®, Hemlibra®, Jivi® and Feiba VH®.

4)    Factor products are covered under the medical benefit as a specialty drug.  

Medical Statement

Coverage for factor products is provided for members with a diagnosis of hemophilia A (D66), hemophilia B (D67), or von Willebrand disease (D68.0) who meet any one of the following criteria:

 

1)     Treatment and/or management of acute bleeding in members with severe hemophilia, and maintenance therapy as needed to maintain trough factor levels at 1% or greater.

2)    Treatment and/or management of acute bleeding episodes for members with mild hemophilia (factor levels of 1% - 5%), such as bleeding episodes associated with surgery or trauma.

3)    Treatment and/or management of acute bleeding in members with von Willebrand disease, and in clinical situations in which patients with von Willebrand disease are at increased risk of bleeding (i.e. surgery or trauma).

4)    Treatment and/or management of significant menorrhagia in women with von Willebrand disease.

 

In addition to the above criteria, coverage for NovoSeven products (Coagulation Factor VIIa [recombinant]) for member with acquired hemophilia (D68.311) or congenital factor VII deficiency (D68.2) when either of the following criteria is met:

 

a)    Treatment and/or management of acute bleeding episodes for members with acquired hemophilia, and in clinical situations in which patients with acquired hemophilia are at increased risk of bleeding (i.e. surgery or trauma).

b)    Treatment and/or management of acute bleeding in member with congenital factor VII deficiency, and in clinical situations in which patients with congenital factor VII deficiency are at increased risk of bleeding (i.e. surgery or trauma).

 

Coverage for Factor XIII Concentrate is provided for members with a diagnosis of congenital Factor XIII (FXIII) deficiency (D68.2) when the following criterion is met:

 

a)    Routine prophylactic treatment of congenital FXIII deficiency in clinical situations in which patients with congenital Factor XIII deficiency are at increased risk of bleeding (i.e. surgery or trauma).

Codes Used In This BI:

 

C9136            Injection, factor VIII, Fc fusion protein, (recombinant), per IU

C9137            Injection, factor VIII (antihemophilic factor, recombinant) PEGylated, 1IU

C9140            Injection factor VIII (antihemophilic factor, recombinant) (Afstyla), 1 IU (new 1/1/17) J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU

J7181             Injection, factor XIII A-subunit, (recombinant), per IU

J7182             Injection, factor VIII, (antihemophilic factor, recombinant), per IU

J7183             Injection, von Willebrand factor complex (human), Wilate, 1 IU VWF: RCO

J7185             Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha), per IU

J7186             Injection, antihemophilic factor VIII/Von Willebrand factor complex (human), per factor VIII I.U.

J7187             Injection, Von Willebrand factor complex (Humate-P), per IU, VWF: RCO

J7189             Factor VIIa (antihemophilic factor, recombinant), per 1 microgram

J7190             Factor VIII (antihemophilic factor [human]) per IU

J7192             Factor VIII (antihemophilic factor, recombinant) per IU

J7193             Factor IX (antihemophilic factor, purified, non-recombinant) per IU

J7194             Factor IX, complex, per IU

J7195             Factor IX (antihemophilic factor, recombinant) per IU

J7200             Injection, factor IX, (antihemophilic factor, recombinant), per IU

J7201             Injection, factor IX, Fc fusion protein (recombinant), per IU

J7205             Injection, factor VIII Fc fusion (recombinant), per IU (Eloctate)

J7208             Injection, factor VIII (antihemophilic factor, recombinant) pegylated

J7209             Injection, factor VIII (antihemophilic, factor, recombinant)(Nuwiq)

J7211             Injection, factor VIII, (antihemophilic factor, recombinant), (Kovaltry), 1 IU

Limits
Intentially left empty
Reference

1)    TUFTS Health Plan Medical Policy – Factor Products.  Reviewed June 12, 2012.

2)    Aetna Pharmacy Clinical Policy Bulletin – Blood Products coagulants.  Reviewed January 2012.

3)    Clinical Pharmacology.  Accessed online November 2012.

4)    National Hemophilia Foundation website www.hemophilia.org

Addendum:

Effective 09/01/2017: Code update

Application to Products

This policy applies to all health plans and products administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD, EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.


Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.