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Asset Publisher
Hemophilia Products - Factor IX: Alphanine SD, Alprolix, BeneFIX, Idelvion, Ixinity, Mononine, Profilnine, Rebinyn, and Rixubis
Policy Number: PH-0339
Intravenous
Last Review Date: 06/04/2024
Date of Origin: 12/16/2014
Dates Reviewed: 12/2014, 04/2015, 05/2015, 09/2015, 12/2015, 03/2016, 06/2016, 12/2016, 06/2017, 09/2017, 11/2017, 11/2018, 03/2019, 02/2020, 08/2020, 04/2021, 06/2021, 07/2021, 06/2022, 09/2022, 06/2023, 04/2024, 06/2024
- Length of Authorization
Coverage is provided for 3 months and may be renewed thereafter, unless otherwise specified*.
Note: The cumulative amount of medication the patient has on-hand will be taken into account for authorizations. Up to 5 ‘on-hand’ doses for the treatment of acute bleeding episodes will be permitted at the time of the authorization request.
* Initial and renewal authorization periods may vary by specific covered indication
- Dosing Limits
A. Quantity Limit (max daily dose) [NDC Unit]:
- N/A
B. Max Units (per dose and over time) [HCPCS Unit]:
Alprolix |
34,500 billable units per 30-day supply |
Idelvion, Rebinyn |
18,400 billable units per 28-day supply |
Ixinity |
64,000 billable units per 28-day supply |
AlphaNine SD, Profilnine, Mononine |
36,800 billable units per 28-day supply |
BeneFIX |
46,000 billable units per 28-day supply |
Rixubis |
55,200 billable units per 28-day supply |
- Initial Approval Criteria1-11,15,18
Hemophilia Management Program |
Requirements for half-life study and inhibitor tests are a part of the hemophilia management program. This information is not meant to replace clinical decision making when initiating or modifying medication therapy and should only be used as a guide. |
Coverage is provided in the following conditions:
Universal Criteria 1-5,7-9
- Therapy NOT used for induction of immune tolerance in patients with Hemophilia B [ONLY the following products]:
-
-
- Alprolix
- Rixubis
- Ixinity
- Idelvion
- Rebinyn
- AlphaNine SD
- Mononine
- BeneFIX; AND
-
-
Hemophilia B (congenital factor IX deficiency aka Christmas disease) † Ф 1-9
- Diagnosis of congenital factor IX deficiency has been confirmed by blood coagulation testing; AND
- Used as treatment in at least one of the following:
- On-demand treatment and control bleeding episodes; OR
- Perioperative management (*Authorizations valid for 1 month); OR
- Routine prophylaxis to prevent or reduce the frequency of bleeding episodes; AND
-
-
- Used as primary prophylaxis in patients with severe factor IX deficiency (factor IX level of <1%); OR
- Used as secondary prophylaxis in patients with at least TWO documented episodes of spontaneous bleeding into joints
-
-
Hemophilia Management Program |
|
† FDA Approved Indication(s); ‡ Compendia Recommended Indication(s); Ф Orphan Drug (NOTE: Ф Only applies to Alphanine SD, Alprolix, BeneFIX, Idelvion, Mononine, Rixubis and Rebinyn)
- Dispensing Requirements for Rendering Providers (Hemophilia Management Program)
- Prescriptions cannot be filled without an expressed need from the patient, caregiver or prescribing practitioner. Auto-filling is not allowed.
- Monthly, rendering provider must submit for authorization of dispensing quantity before delivering factor product. Information submitted must include:
-
- Original prescription information, requested amount to be dispensed, vial sizes available to be ordered from the manufacturer, and patient clinical history (including patient product inventory and bleed history)
- Factor dose should not exceed +1% of the prescribed dose and a maximum of three vials may be dispensed per dose. If unable to provide factor dosing within the required threshold, below the required threshold, the lowest possible dose able to be achieved above +1% should be dispensed. Prescribed dose should not be increased to meet assay management requirements.
-
- The cumulative amount of medication(s) the patient has on-hand should be taken into account when dispensing factor product. Patients should not have more than 5 extra doses on-hand for the treatment of acute bleeding episodes.
- Dispensing requirements for renderings providers are a part of the hemophilia management program. This information is not meant to replace clinical decision making when initiating or modifying medication therapy and should only be used as a guide.
- Renewal Criteria 1-11,15
Coverage can be renewed based upon the following criteria:
- Patient continues to meet universal and other indication-specific relevant criteria such as concomitant therapy requirements (not including prerequisite therapy), performance status, etc. identified in section III; AND
- Absence of unacceptable toxicity from the drug. Examples of unacceptable toxicity include: anaphylaxis and hypersensitivity reactions (e.g., angioedema, chest tightness, hypotension, urticaria, wheezing, dyspnea, etc.), thromboembolic events (pulmonary embolism, venous thrombosis, and arterial thrombosis), development of neutralizing antibodies (inhibitors), nephrotic syndrome, etc.; AND
- Any increases in dose must be supported by an acceptable clinical rationale (i.e. weight gain, half-life study results, increase in breakthrough bleeding when patient is fully adherent to therapy, etc.); AND
- The cumulative amount of medication(s) the patient has on-hand will be taken into account when authorizing. The authorization will allow up to 5 doses on-hand for the treatment of acute bleeding episodes as needed for the duration of the authorization; AND
On-demand treatment of bleeding episodes and control bleeding episodes
- Renewals will be approved for a 6 month authorization period
Perioperative management of bleeding
- Coverage may NOT be renewed
Routine prophylaxis to reduce the frequency of bleeding episodes
- Renewals will be approved for a 12 month authorization period; AND
- Patient has demonstrated a beneficial response to therapy (i.e., the frequency of bleeding episodes has decreased from pre-treatment baseline)
- Dosage/Administration1-9
Alprolix
Indication |
Dose |
On-demand treatment and control of bleeding episodes Hemophilia B |
One unit per kilogram body weight increases the circulating Factor IX level by 1% (IU/dL) in adults and children ≥6 years of age and by 0.6% (IU/dL) in children under 6 years of age. Estimate the required dose or the expected in vivo peak increase in Factor IX level expressed as IU/dL (or % of normal) using the following: IU/dL (or % of normal) = [Total Dose (IU)/Body Weight (kg)] x Recovery (IU/dL per IU/kg) Minor and Moderate Circulating Factor IX required (% of normal) = 30-60 IU/dL - Repeat every 48 hours as needed Major Circulating Factor IX required (% of normal) = 80-100 IU/dL - Consider repeat dose after 6-10 hours, then every 24 hours for 3 days, then every 48 hours until healing achieved. |
Perioperative management Hemophilia B |
One unit per kilogram body weight increases the circulating Factor IX level by 1% (IU/dL) in adults and children ≥6 years of age and by 0.6% (IU/dL) in children under 6 years of age. Estimate the required dose or the expected in vivo peak increase in Factor IX level expressed as IU/dL (or % of normal) using the following: IU/dL (or % of normal) = [Total Dose (IU)/Body Weight (kg)] x Recovery (IU/dL per IU/kg) Minor Circulating Factor IX required (% of normal) = 50-80 IU/dL - Repeat every 24-48 hours as needed, until bleeding stops and healing is achieved. Major Circulating Factor IX required (% of normal) = 60-100 IU/dL (initial level) - Consider repeat dose after 6-10 hours, then every 24 hours for 3 days, then every 48 hours until bleeding stops and healing achieved. |
Routine prophylaxis Hemophilia B |
Adults and adolescents ≥12 years of age 50 IU/kg once weekly or 100 IU/kg once every 10 days. Adjust dosing regimen based on individual response. Children <12 years of age Start with 60 IU/kg once weekly. Adjust dosing regimen based on individual response. More frequent or higher doses may be needed in children <12 years of age, especially in children <6 years of age. |
AlphaNine SD
Indication |
Dose |
On-demand treatment and control of bleeding episodes Hemophilia B |
One unit per kilogram body weight increases the circulating Factor IX level by 1% (IU/dL). Number of Factor IX IU required = body wt (kg) x Desired increase in Plasma Factor IX (percent) x 1.0 IU/kg Minor Circulating Factor IX required (20 – 30 % of normal) = 20-30 IU/kg - Repeat every 12 hours as needed for 1-2 days Moderate Circulating Factor IX required (25 - 50% of normal) = 25-50 IU/kg - Repeat every 12 hours as needed for 2-7 days Major Circulating Factor IX required (50% of normal) = 30-50 IU/kg - Repeat dose every 12 hours as needed for 3-5 days. Following this treatment period, FIX levels should be maintained at 20% (20 IU FIX/kg/twice daily) until healing has been achieved. Major hemorrhages may require treatment for up to 10 days |
Routine prophylaxis Hemophilia B § |
25-40 IU/kg two times weekly or 15-30 IU/kg two times weekly. Adjust dosing regimen based on individual response. |
Perioperative management Hemophilia B |
Prior to surgery, FIX should be brought to 50-100% of normal (50-100 IU/kg repeat every 12 hours). For the next 7 to 10 days, or until healing has been achieved, the patient should be maintained at 50-100% FIX levels (50-100 IU/kg every 12 hours). |
BeneFIX
Indication |
Dose |
On-demand treatment and control of bleeding episodes and Perioperative management Hemophilia B |
One IU per kilogram body weight increases the circulating Factor IX level by 0.8 ± 0.2 IU/dL in adolescents/adults (≥12 years) and 0.7 ± 0.3 IU/dL in children (< 12 years). Initial dose: Number of Factor IX IU required (IU) = body weight (kg) x desired factor IX increase (% of normal or IU/dL) x reciprocal of observed recovery (IU/kg per IU/dL)
Dosage and duration of treatment with BeneFIX depend on the severity of the factor IX deficiency, the location and extent of bleeding, and the patient's clinical condition, age and recovery of factor IX. |
Routine prophylaxis Hemophilia B |
|
Idelvion
Indication |
Dose |
On-demand treatment and control of bleeding episodes Hemophilia B |
Minor/Moderate Desired peak Factor IX Level (% of normal or IU/dL): 30-60, dosed every 48-72 hours for at least 1 day until healing is achieved Major Desired peak Factor IX Level (% of normal or IU/dL): 60-100, dosed every 48-72 hours for 7-14 days until healing is achieved. Maintenance dose is weekly. |
Perioperative management Hemophilia B |
Minor Desired peak Factor IX Level (% of normal or IU/dL): 50-80, dosed every 48-72 hours for at least 1 day until healing is achieved Major Desired peak Factor IX Level (% of normal or IU/dL): 60-100, dosed every 48-72 hours for 7-14 days until healing is achieved. Repeat dose every 48-72 hours for the first week or until healing is achieved. Maintenance dose is once or twice weekly. |
Routine prophylaxis Hemophilia B |
Patients ≥12 years of age: 25-40 IU/kg body weight every 7 days. Patients who are well-controlled on this regimen may be switched to a 14-day interval at 50-75 IU/kg body weight. Patients <12 years of age: 40-55 IU/kg body weight every 7 days. |
Ixinity
Indication |
Dose |
On-demand treatment and control of bleeding episodes Hemophilia B |
One IU per kilogram body weight increases the circulating activity of Factor IX by 0.79 IU/dL for patients <12 years of age and 0.98 IU/dL for patients ≥ 12 years of age.
|
Perioperative management Hemophilia B |
One IU per kilogram body weight increases the circulating activity of Factor IX by 0.79 IU/dL for patients <12 years of age and 0.98 IU/dL for patients ≥ 12 years of age. Initial dose: Required factor IX units (IU) = body weight (kg) x desired factor IX increase (% of normal or IU/dL) x reciprocal of observed recovery (IU/kg per IU/dL) Maintenance dose: Depends upon the type of bleed or surgery, clinical response, and the severity of the underlying factor IX deficiency Minor surgery:
Major surgery:
|
Routine prophylaxis Hemophilia B |
Patients ≥ 12 years of age:
Patients < 12 years of age:
NOTE: Adjust the dosing regimen (dose or frequency) based on the patient's clinical response. Adjust the dose based on the individual patient’s age, bleeding pattern, and physical activity. |
Mononine
Indication |
Dose |
On-demand treatment and control of bleeding episodes and Perioperative management Hemophilia B |
One unit per kilogram body weight increases the circulating Factor IX level by 1% (IU/dL). Estimate the required dose with the following formula: Number of Factor IX IU required (IU) = Body Weight (in kg) x desired Factor IX increase (% or IU/dL normal) x 1.0 IU/kg [per IU/dL] Minor Spontaneous Hemorrhage Prophylaxis Circulating Factor IX required (% of normal)(15-25%) = up to 20-30 IU/kg for one dose. Repeat in 24 hours if necessary. Major Trauma or Surgery Circulating Factor IX required (% of normal)(25-50%) = up to 75 IU/kg dosed every 18-30 hours depending on T1/2 and measured Factor IX levels. Continue for up to 10 days depending upon nature of insult. |
Profilnine
Indication |
Dose |
On-demand treatment and control of bleeding episodes Hemophilia B |
Patients ≥ 18 years of age: One unit per kilogram body weight increases the circulating Factor IX level by 1% (IU/dL). Number of Factor IX IU required = body wt (kg) x Desired increase in Plasma Factor IX (percent) x 1.0 IU/kg Minor to Moderate Single dose of product sufficient to raise plasma Factor IX levels to 20-30% of normal. 20-30 IU/kg every 16-24 hours until hemorrhage stops and healing is achieved. For minor, may repeat for 1-2 days, for moderate, may repeat for 2-7 days. Major Single dose of product sufficient to raise plasma Factor IX levels to 30-50% of normal. 30-50 IU/kg every 16-24 hours for up to 3-10 days. Following this treatment period, maintain Factor IX levels at 20% of normal until healing has been achieved. |
Routine prophylaxis Hemophilia B § |
Patients ≥ 18 years of age: 25-40 IU/kg two times weekly or 15-30 IU/kg two times weekly. Adjust dosing regimen based on individual response. |
Perioperative management Hemophilia B |
Patients ≥ 18 years of age: Surgery associated with bleeding in Factor IX deficient patients require Factor IX levels of 30-50% of normal. For dental extractions, the Factor IX level should be raised to 50% of normal immediately prior to procedure. 30-50 IU/kg every 16-24 hours for 7-10 days until healing is achieved. Maintain Factor IX levels at 30-50% of normal until healing has been achieved. |
Rebinyn
Indication |
Dose |
On-demand treatment and control of bleeding episodes Hemophilia B |
Minor and Moderate 40 IU/kg of actual body weight. A single dose should be sufficient for minor and moderate bleeds. Additional doses of 40 IU/kg can be given. Major 80 IU/kg of actual body weight. Additional doses of 40 IU/kg can be given. |
Perioperative management Hemophilia B |
Minor Pre-op: 40 IU/kg of actual body weight (single pre-op dose should be sufficient) Post-op: Additional doses can be given if required Major Pre-op: 80 IU/kg of actual body weight Peri/Post-op: 40 IU/kg of actual body weight. As clinically needed for the perioperative management of bleeding, repeated doses of 40 IU/kg (in 1-3 day intervals) within the first week after major surgery may be administered. Due to the long half-life, the frequency of dosing in the post-surgical setting may be extended to once weekly after the first week until bleeding stops and healing is achieved. |
Routine prophylaxis Hemophilia B |
40 IU/kg once weekly. Adjust the dose based on the individual patient’s bleeding pattern and physical activity. |
Rixubis
Indication |
Dose |
On-demand treatment and control of bleeding episodes Hemophilia B |
One IU per kilogram body weight increases the circulating activity of Factor IX by 0.7 IU/dL for patients <12 years of age and 0.9 IU/dL for patients ≥ 12 years of age. Initial dose = body wt (kg) x desired factor IX increase (percent of normal or IU/dL) x reciprocal of observed recovery (IU/kg per IU/dL) Minor Circulating Factor IX level required (% or IU/dL) = 20-30 every 12 - 24 hours for at least 1 day, until healing is achieved Moderate Circulating Factor IX level required (% or IU/dL) = 25-50 every 12 - 24 hours for 2-7 days, until bleeding stops and healing is achieved Major Circulating Factor IX level required (% or IU/dL) = 50-100 every 12 - 24 hours for 7-10 days, until bleeding stops and healing is achieved |
Routine prophylaxis Hemophilia B |
Dosing for previously treated patients (PTPs): Patients <12 years of age 60 – 80 IU/kg twice weekly Patients ≥ 12 years of age 40 – 60 IU/kg twice weekly Adjust the dose based on the individual patient’s age, bleeding pattern, and physical activity. |
Perioperative management Hemophilia B |
One IU per kilogram body weight increases the circulating activity of Factor IX by 0.7 IU/dL for patients <12 years of age and 0.9 IU/dL for patients ≥ 12 years of age. Circulating Factor IX level required (% or IU/dL) = 30-60 every 24 hours for at least 1 day, until healing is achieved Major Circulating Factor IX level required (% or IU/dL) = 80-100 every 8 - 24 hours for 7-10 days, until bleeding stops and healing is achieved |
§ Utrecht and/or Malmö protocols used as basis for dosing
- Billing Code/Availability Information
Hemophilia products are covered under the prescription drug benefits of a member’s plan. Claims for hemophilia products submitted for payment under any benefit section of the member’s plan (other than prescription drug benefits) will be denied as non-covered benefits. The only exceptions to this are claims for hemophilia products used in an inpatient facility or for emergency use, accidents or surgery (Type Services A, S, or 2) in the following settings:
If home health nursing assistance is needed for drug administration, the hemophilia product should be accessed and paid through the member’s prescription benefit coverage. Nursing services should be billed only for the administration of the hemophilia product under the member’s home health benefits. |
HCPCS Code(s) & NDC(s):
Drug |
Manufacturer |
HCPCS Code |
1 Billable Unit Equiv. |
Vial Size |
NDC |
AlphaNine SD |
Grifols Biologicals Inc. |
J7193 |
1 IU |
500 units |
68516-3610 68516-3607 |
1000 units |
68516-3611 68516-3608 |
||||
1500 units |
68516-3612 68516-3609 |
||||
Mononine |
CSL Behring LLC |
J7193 |
1 IU |
1000 units |
00053-6233 |
Alprolix |
Bioverativ Therapeutics Inc. |
J7201 |
1 IU |
250 units |
71104-0966 |
500 units |
71104-0911 |
||||
1000 units |
71104-0922 |
||||
2000 units |
71104-0933 |
||||
3000 units |
71104-0944 |
||||
4000 units |
71104-0977 |
||||
Profilnine |
Grifols Biologicals LLC |
J7194
|
1 IU |
500 units |
68516-3210 68516-3207 |
1000 units |
68516-3211 68516-3208 |
||||
1500 units |
68516-3212 68516-3209 |
||||
BeneFIX |
Wyeth Pharmaceuticals LLC |
J7195 |
1 IU |
250 units |
58394-0633 |
500 units |
58394-0634 |
||||
1000 units |
58394-0635 |
||||
2000 units |
58394-0636 |
||||
3000 units |
58394-0637 |
||||
Ixinity |
Medexus Pharma, Inc. |
J7213 |
1 IU |
250 units |
59137-0287 |
500 units |
59137-0282 |
||||
1000 units |
59137-0283 |
||||
1500 units |
59137-0284 |
||||
2000 units |
59137-0288 |
||||
3000 units |
59137-0289 |
||||
Rixubis |
Takeda Pharmaceuticals U.S.A., Inc. |
J7200 |
1 IU |
250 units |
00944-3026 |
500 units |
00944-3028 |
||||
1000 units |
00944-3030 |
||||
2000 units |
00944-3032 |
||||
3000 units |
00944-3034 |
||||
Idelvion |
CSL Behring LLC |
J7202 |
1 IU |
250 units |
69911-0864 |
500 units |
69911-0865 |
||||
1000 units |
69911-0866 |
||||
2000 units |
69911-0867 |
||||
3500 units |
69911-0869 |
||||
Rebinyn |
Novo Nordisk Inc. |
J7203 |
1 IU |
500 units |
00169-7905 |
1000 units |
00169-7901 |
||||
2000 units |
00169-7902 |
||||
3000 units |
00169-7903 |
- References
- AlphaNine SD [package insert]. Los Angeles, CA; Grifols Biologicals Inc.; November 2022. Accessed May 2024.
- Alprolix [package insert]. Waltham, MA; Bioverativ Therapeutics Inc.; May 2023. Accessed May 2024.
- BeneFIX [package insert]. Philadelphia, PA; Wyeth Pharmaceuticals LLC; November 2022. Accessed May 2024.
- Ixinity [package insert]. Chicago, IL. Medexus Pharma, Inc.; March 2024. Accessed May 2024.
- Mononine [package insert]. Kankakee, IL; CSL Behring LLC; December 2018. Accessed May 2024.
- Profilnine [package insert]. Los Angeles, CA; Grifols Biologicals LLC; June 2023. Accessed May 2024.
- Rebinyn [package insert]. Plainsboro, NJ; Novo Nordisk Inc.; August 2022. Accessed May 2024.
- Rixubis [package insert]. Lexington, MA; Takeda Pharmaceuticals U.S.A., Inc.; March 2023; Accessed May 2024.
- Idelvion [package insert]. Kankakee, IL; CSL Behring LLC; June 2023. Accessed May 2024.
- MASAC Recommendations Concerning Products Licensed For The Treatment Of Hemophilia And Selected Disorders of the Coagulation System. Revised April 11, 2024. National Hemophilia Foundation. MASAC Document #284; April 2024. Available at: https://www.bleeding.org. Accessed May 2024.
- Guidelines for the Management of Hemophilia. 3rd Edition. World Federation of Hemophilia 2020. Available at: https://www1.wfh.org/publications/files/pdf-1863.pdf. Accessed May 2024.
- Annual Review of Factor Replacement Products. Oklahoma Health Care Authority Review Board. Updated Dec 2020. Accessed May 2024.
- Graham A1, Jaworski K. Pharmacokinetic analysis of anti-hemophilic factor in the obese patient. Haemophilia. 2014 Mar;20(2):226-9.
- Croteau SE1, Neufeld EJ. Transition considerations for extended half-life factor products. Haemophilia. 2015 May;21(3):285-8.
- Mingot-Castellano, et al. Application of Pharmacokinetics Programs in Optimization of Haemostatic Treatment in Severe Hemophilia a Patients: Changes in Consumption, Clinical Outcomes and Quality of Life. Blood. 2014 December; 124 (21).
- MASAC Recommendation Concerning Prophylaxis for Hemophilia A and B with and without Inhibitors. Revised April 27, 2022. National Hemophilia Foundation. MASAC Document #267; April 2022. Available at: https://www.bleeding.org. Accessed May 2024.
- Rayment R, Chalmers E, Forsyth K, et al. Guidelines on the use of prophylactic factor replacement for children and adults with Haemophilia A and B. B J Haem:190;5, Sep 2020. https://doi.org/10.1111/bjh.16704. Accessed May 2024.
- Hoots, WK. (2024). Hemophilia A and B: Routine management including prophylaxis. In Leung LLK, Tirnauer JS (Eds.), UptoDate. Last updated: April 16, 2024. Accessed May 13, 2024. Available from https://www.uptodate.com/contents/hemophilia-a-and-b-routine-management-including-prophylaxis?search=hemophilia%20a&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#H978189854
- First Coast Service Options, Inc. Local Coverage Article: Billing and Coding: Hemophilia Factor Products (A56482). Centers for Medicare & Medicaid Services Inc. Updated on 09/29/2023 with effective date 10/01/2023. Accessed May 2024.
- Palmetto GBA. Local Coverage Article: Billing and Coding: Guidance for Anti-Inhibitor Coagulant Complex (AICC) National Coverage Determination (NCD) 110.3 (A56065). Centers for Medicare & Medicaid Services Inc. Updated on 11/14/2022 with effective date 11/24/2022. Accessed May 2024.
- Novitas Solutions, Inc. Local Coverage Article: Billing and Coding: Hemophilia Factor Products (A56433). Centers for Medicare & Medicaid Services Inc. Updated on 09/29/2023 with effective date 10/01/2023. Accessed May 2024.
Appendix 1 – Covered Diagnosis Codes
ICD-10 |
ICD-10 Description |
D67 |
Hereditary factor IX deficiency |
Appendix 2 – Centers for Medicare and Medicaid Services (CMS)
The preceding information is intended for non-Medicare coverage determinations. Medicare coverage for outpatient (Part B) drugs is outlined in the Medicare Benefit Policy Manual (Pub. 100-2), Chapter 15, §50 Drugs and Biologicals. In addition, National Coverage Determinations (NCDs) and/or Local Coverage Determinations (LCDs) may exist and compliance with these policies is required where applicable. Local Coverage Articles (LCAs) may also exist for claims payment purposes or to clarify benefit eligibility under Part B for drugs which may be self-administered. The following link may be used to search for NCD, LCD, or LCA documents: https://www.cms.gov/medicare-coverage-database/search.aspx. Additional indications, including any preceding information, may be applied at the discretion of the health plan.
Medicare Part B Covered Diagnosis Codes |
||
Jurisdiction |
NCD/LCA/LCD Document (s) |
Contractor |
H,L |
A56433 |
Novitas Solutions, Inc. |
J, M |
A56065 |
Palmetto GBA |
N |
A56482 |
First Coast Service Options, Inc. Insurance Corp (WPS) |
Medicare Part B Administrative Contractor (MAC) Jurisdictions |
||
Jurisdiction |
Applicable State/US Territory |
Contractor |
E (1) |
CA, HI, NV, AS, GU, CNMI |
Noridian Healthcare Solutions, LLC |
F (2 & 3) |
AK, WA, OR, ID, ND, SD, MT, WY, UT, AZ |
Noridian Healthcare Solutions, LLC |
5 |
KS, NE, IA, MO |
Wisconsin Physicians Service Insurance Corp (WPS) |
6 |
MN, WI, IL |
National Government Services, Inc. (NGS) |
H (4 & 7) |
LA, AR, MS, TX, OK, CO, NM |
Novitas Solutions, Inc. |
8 |
MI, IN |
Wisconsin Physicians Service Insurance Corp (WPS) |
N (9) |
FL, PR, VI |
First Coast Service Options, Inc. |
J (10) |
TN, GA, AL |
Palmetto GBA |
M (11) |
NC, SC, WV, VA (excluding below) |
Palmetto GBA |
L (12) |
DE, MD, PA, NJ, DC (includes Arlington & Fairfax counties and the city of Alexandria in VA) |
Novitas Solutions, Inc. |
K (13 & 14) |
NY, CT, MA, RI, VT, ME, NH |
National Government Services, Inc. (NGS) |
15 |
KY, OH |
CGS Administrators, LLC |
FACTOR IX_HEMOPHILIA PRODUCTS - Prior Auth Criteria |
|