Medical Policy Revision: Ipilimumab (Yervoy)

Effective April 13, 2015, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider claims for ipilimumab (Yervoy®).

Based on the guidelines of our revised medical policy, Ipilimumab (Yervoy®), claims submitted for services provided April 13, 2015 and after to patients over 18 years of age that include HCPCS Code J9228 and one or more of the diagnosis codes listed below will pend while information to determine medical appropriateness is requested and reviewed.

• ICD-9 diagnosis codes: 172.0, 172.1, 172.2, 172.3, 172.4, 172.5, 172.6, 172.7, 172.8, 172.9, 198.2.
• ICD-10 diagnosis codes: C43.0, C43.10, C43.11, C43.12, C43.20, C43.21, C43.22, C43.30, C43.31, C43.39, C43.4, C43.51, C43.52, C43.59, C43.60, C43.61, C43.62, C43.70, C43.71, C43.72, C43.8, C43.9, C79.2.

For services provided <date> and after, HCPCS Code J9228 will be denied as an investigational service if submitted:

• With a diagnosis code other than those listed above for patients over 18 years of age.
• Regardless of the diagnosis submitted for patients 18 years of age and younger.

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 and Blue Shield Association or Prime Therapeutics LLC.