Medical Policy Revision: Mozobil® (Plerixafor injection)
Effective September 14, 2015, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider claims for Mozobil.
Based on the guidelines of our revised medical policy, Mozobil® (Plerixafor injection):
- Claims that include HCPCS code J2562 for services provided September 14, 2015 and after that also include one or more diagnosis codes related to: lymphosarcoma and reticulosarcoma and other specified malignant tumors of lymphatic tissue; Hodgkin's disease; other malignant neoplasms of lymphoid and histiocytic tissue; or multiple myeloma and immunoproliferative neoplasms, will pend while information required to determine medical necessity is requested and reviewed.
- HCPCS code J2562 submitted on claims for services provided on and after September 14, 2015, that also include a diagnosis code in a category other that one of those listed above, will be denied as an investigational/experimental service.
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 September 14, 2015.
Mozobil® is a registered trademark of Sanofi-Aventis U.S., LLC.