D66 — Hereditary factor VIII deficiency
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Policy content not provided; unable to determine required documentation, prior authorization, or forms for AICC claims—manual review of the full policy required.
- For Idarucizumab (Praxbind): documentation that the patient is being treated with dabigatran and there is a need for emergency surgery/urgent procedure or life-threatening/uncontrolled bleeding (single 5 g IV dose per labeling).
- For Coagadex, Corifact, Tretten, Thrombate III/ATryn: documentation of diagnosed congenital deficiency (hereditary Factor X deficiency; congenital Factor XIII deficiency; congenital Factor XIII A-subunit deficiency; hereditary antithrombin deficiency), including supporting laboratory confirmation (factor activity levels) where applicable, and indication for prophylaxis, on-demand therapy, or perioperative management.
Key Coverage Criteria
- Policy content not provided; unable to determine covered indications for AICC NCD 110.3—manual review of the full policy required.
- Tretten is not for use in patients with congenital factor XIII B-subunit deficiency. (explicit in Tretten section)
- D66 Hereditary factor VIII deficiency [Hemophilia A]
- Praxbind is indicated in patients treated with Pradaxa when reversal of the anticoagulant effects of dabigatran is needed: For emergency surgery/urgent procedures
- Praxbind is indicated in patients treated with Pradaxa when reversal of the anticoagulant effects of dabigatran is needed: In life-threatening or uncontrolled bleeding.
- Kcentra for the urgent reversal of anticoagulation in adults with major bleeding (section heading: "Kcentra for Reversal of VKA Anti-Coagulation")
5 Active Policies
AMBETTER-CG-Hema-Cond-(nonCA)--2025.1 — Concert Genetic Testing: Hematologic Conditions (non-cancerous)
CIGNA-0538 — Flow Cytometry - (0538)
AETNA-CPB-0131 — Clotting Factors
A56065 — Billing and Coding: Guidance for Anti-Inhibitor Coagulant Complex (AICC) National Coverage Determination (NCD) 110.3
RX501.128 — Valoctocogene Roxaparvovec-rvox
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