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.
- Documentation that patient is not currently using antiviral therapy for hepatitis B or C.
- Hepatitis B testing: documentation that hepatitis B surface antigen is negative.
- Hepatitis C testing: documentation that HCV antibody is negative OR if HCV antibody positive, documentation that HCV RNA is negative.
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 (fidanacogene elaparvovec-dzkt) for the treatment of Hemophilia B (congenital factor IX deficiency) in patients 18 years of age or older when ALL of the following are met: patient is ≥18 years; diagnosis of severe hemophilia B with endogenous factor IX levels <1% of normal (<0.01 IU/mL) OR diagnosis of moderately severe hemophilia B with endogenous factor IX levels ≥1% to ≤2% (≥0.01 to ≤0.02 IU/mL); patient has current or historical life‑threatening hemorrhage OR repeated, serious spontan [...]
- Hemgenix (etranacogene dezaparvovec‑drlb) for the treatment of Hemophilia B (congenital factor IX deficiency) in patients 18 years of age or older when ALL of the following are met: patient is ≥18 years; diagnosis of severe hemophilia B with endogenous factor IX levels <1% of normal (<0.01 IU/mL) OR diagnosis of moderately severe hemophilia B with endogenous factor IX levels ≥1% to ≤2% (≥0.01 to ≤0.02 IU/mL); patient has current or historical life‑threatening hemorrhage OR repeated, serious spon [...]
- Diagnosis code referenced: D67 (Hereditary factor IX deficiency) — Hemophilia B
- 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).
4 Active Policies
AMBETTER-CG-Hema-Cond-(nonCA)--2025.1 — Concert Genetic Testing: Hematologic Conditions (non-cancerous)
CIGNA-0538 — Flow Cytometry - (0538)
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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