C9172 — Injection, fidanacogene elaparvovec-dzkt, per therapeutic dose
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- Etranacogene dezaparvovec-drlb is consideredmedically necessaryin individuals who meetallof the following criteria:
- Diagnosis of hemophilia B;and
- Age 18 years or older;and
- Baseline factor IX level is less than 1 international unit (IU)/deciliter (dL) (or 1% endogenous factor IX);and
- No contraindications to infusion (if any of the following are present, treatment is contraindicated):Active infection;orImmunosuppressive disorder;orLiver cirrhosis;orActive hepatitis B or C;orAlanine transaminase (ALT) greater than 3 times the upper limit of normal;orBilirubin greater than 3 times the upper limit of normal;orAlkaline phosphatase greater than 3 times the upper limit of normal;orInternational normalized ratio (INR) greater than1.4.;orPrior infusion of gene therapy for hemophilia [...]
- Active infection;or
1 Active Policy
ANTHEM-MED.00135 — MED.00135 Gene Therapy for Hemophilia
Related Codes
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