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Medical Policy Revision: H.P. Acthar Gel

Effective April 13, 2015, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider certain claims for H.P. Acthar® Gel. Based on the guidelines of our revised medical policy, H.P. Acthar Gel, claims submitted for services provided April 13, 2015 and after that include HCPCS Code J0800 and one of the diagnosis codes listed below will pend while information to determine medical appropriateness is requested and reviewed.

  • ICD-9 diagnosis code: 345.60, 345.61, 583.81.
  • ICD-10 diagnosis code: G40.401, G40.409, G40.411, G40.419, E09.21, E09.22, E09.29, M32.14, M32.15, M35.04, N08, N16.

HCPCS code J0800, when submitted with a diagnosis code other than those noted above will be denied as not medically necessary. 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 April 13, 2015. This article contains references to a brand name prescription medicine that is a registered mark of a pharmaceutical manufacturer that is not affiliated with Horizon Blue Cross Blue Shield of New Jersey, the Blue Cross Blue Shield Association or Prime Therapeutics LLC.

Published on: January 12, 2015, 08:00 a.m. ET
Last updated on: May 6, 2021, 03:59 a.m. ET