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Medical Policy Revision: Drug Therapy for Hereditary Angioedema

Effective February 25, 2015, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider claims related to drug therapy to treat hereditary angioedema.

Based on the guidelines of our revised medical policy, Drug Therapy for Hereditary Angioedema [Cinryze, Berinert (Human C1 Inhibitor), Kalbitor (Ecallantide), Firazyr (Icatibant), Ruconest (C1 esterase inhibitor [recombinant])], on and after a service date of February 25, 2015, claims submitted for drug therapy to treat hereditary angioedema will pend while information required for us to determine medical necessity is requested and reviewed.

Claims submitted with ICD-9 diagnosis codes 277.6, 995.1 or ICD-10 diagnosis codes D84.1, T78.3xxA, T78.3xxD will pend for additional information based on the submitted HCPCS code and the age of the patient age as shown in the table below.

HCPCS codesWill pend for additional information if the patient is ...

J059713 years of ager or older

J05989 years of age or older

J129012 years of age or older

J174418 years of age or older

Review this revised policy in our online Medical Policy Manual.

Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been cancelled or postponed, the changes will be applied to claims for dates of service on and after February 25, 2015.

Published on: November 26, 2014, 09:20 a.m. ET
Last updated on: November 24, 2020, 23:15 p.m. ET