A91 — Dengue hemorrhagic fever
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documentation that the requested medication will be used to mobilize hematopoietic stem cells for collection prior to transplantation (documentation of planned autologous transplantation or intent to collect for transplant).
- Documentation of pregnancy/lactation status and any counseling regarding risks to pregnant/nursing members.
- Clinical notes addressing prior mobilization attempts and rationale for plerixafor (particularly relevant for poor mobilizers or re-mobilization scenarios), if applicable.
- Relevant laboratory data as applicable (e.g., renal function/creatinine clearance for dose adjustment).
Key Coverage Criteria
- Aetna considers plerixafor (Mozobil or generic plerixafor) injection medically necessary when all of the following criteria are met: The requested medicaton will be used to mobilize hematopoietic stem cells for collection prior to transplantation; and The requested medication will be administered after the member has received a granulocyte-colony stimulating factor (G-CSF) (e.g., filgrastim) or chemo-mobilization; and The requested medication will not be used beyond 4 consecutive days or after c [...]
- Continuation of plerixafor (Mozobil) injection therapy is medically necessary for all members (including new members) who meet all initial medical necessity selection criteria.
- FDA-approved indication (background): Mozobil is indicated in combination with granulocyte-colony stimulating factor (G-CSF) to mobilize hematopoietic stem cells (HSCs) to the peripheral blood for collection and subsequent autologous transplantation in patients with non-Hodgkin’s lymphoma or multiple myeloma.
- HCPCS code covered if selection criteria are met: J2562 Injection, plerixafor, 1 mg [Mozobil].
- ICD-10 codes covered if selection criteria are met: C82.00 - C82.99; C84.00 - C84.49; C84.a0 - C84.99; C85.10 - C85.99; C86.0 - C86.6; C91.40 - C91.42; C96.0 - C96.4; C96.a - C96.9; Other malignant neoplasms of lymphoid and histiocytic tissue; C83.00 - C83.99; C84.60 - C84.79; C88.4; C88.8 - C90.32 (Malignant immunoproliferative diseases and multiple myeloma and malignant plasma cell neoplasms).
- Compendial use listed: Hematopoietic cell transplantation.
1 Active Policy
AETNA-CPB-0779 — Plerixafor
Related Codes
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