D67, Hereditary factor IX 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.
- Reimbursement will only be provided if a requested service(s) is submitted in accordance with the relevant criteria outlined in the applicable Coverage Policy, including covered diagnosis and/or procedure code(s).
- Claims submitted for services that are not accompanied by covered code(s) under the applicable Coverage Policy will be denied as not covered.
- When billing, providers must use the most appropriate codes as of the effective date of the submission.
Key Coverage Criteria
- Policy content not provided; unable to determine covered indications for AICC NCD 110.3—manual review of the full policy required.
- Beqvez is proven and medically necessary for the treatment of Hemophilia B (congenital factor IX deficiency) when all of the following criteria are met: 1) Patient is 18 years of age or older; and 2) One of the following: a) Both of the following: i) Diagnosis of severe hemophilia B; and ii) Documentation of endogenous factor IX levels less than 1% of normal factor IX (< 0.01 IU/mL) or b) All of the following: i) Diagnosis of moderately severe hemophilia B; and ii) Documentation of endogenous fa [...]
- Flow cytometry is considered medically necessary for the evaluation of any of the following: Hematopoietic/hematologic cancers; Immunodeficiency disorders, including human immunodeficiency virus (HIV) and acquired immunodeficiency virus syndrome (AIDS); Paroxysmal nocturnal hemoglobinuria; Gestational trophoblastic disease; Transplantation.
- Diagnosis and/or evaluation of hematopoietic cancers, including lymphomas and leukemia, plasma cell neoplasms, myelodysplastic syndromes, myeloproliferative neoplasms, and certain anemias (as described in General Background).
- Monitoring lymphocyte populations (e.g., T-cells, NK cells), including CD4 and CD8 counts and CD4/CD8 ratio for management of HIV disease (eligibility for antiretroviral therapy, monitoring immune restoration, guiding treatment against opportunistic infections).
- Detection of minimal residual disease and detection of antigens used as therapeutic drug targets for cancer therapy (hematologic malignancies).
4 Active Policies
AMBETTER-CG-Hema-Cond-(nonCA)--2025.1, Concert Genetic Testing: Hematologic Conditions (non-cancerous)
CIGNA-0538, Flow Cytometry
UHC-POL-gene-therapies-hemophilia, Gene Therapies for Hemophilia B
A56065, Billing and Coding: Guidance for Anti-Inhibitor Coagulant Complex (AICC) National Coverage Determination (NCD) 110.3
Related Codes
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