D69.2 — Other nonthrombocytopenic purpura
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documentation of prior therapies and inadequate response or intolerance (e.g., corticosteroids, immunoglobulins, splenectomy) for ITP initial approval.
- Untransfused baseline platelet count prior to initiation (must be <30 x 10^9/L) OR documentation of platelet count at diagnosis between 30 x 10^9/L and 50 x 10^9/L with symptomatic bleeding or documented bleeding risk factors (see Appendix examples).
- For CIT: documentation of platelet count <100 x 10^9/L for at least 3–4 weeks following the last chemotherapy administration, or documentation that chemotherapy administration has been delayed related to thrombocytopenia.
- For continuation: documentation of current platelet counts (specific thresholds outlined in continuation criteria) and documentation of clinical benefit where required (e.g., increased platelet counts, decreased bleeding events, reduced need for platelet transfusions).
Key Coverage Criteria
- Continuation-of-therapy indications (examples): - ITP continuation: members meeting any of the following: current platelet count <50 x 10^9/L with platelet count not sufficient to prevent clinically important bleeding and who have not received a maximal Nplate dose for at least 4 weeks; or current platelet count <50 x 10^9/L for whom current platelet count is sufficient to prevent clinically important bleeding; or current platelet count 50 x 10^9/L to 200 x 10^9/L; or current platelet count >20 [...]
- Pediatric use per FDA (background): Nplate is FDA-indicated for pediatric patients 1 year of age or older with ITP for at least 6 months who have had an insufficient response to corticosteroids, immunoglobulins, or splenectomy (policy includes pediatric dosing guidance for ages 1–17).
- Covered ICD-10 codes (if selection criteria are met): D46.22, D46.c, D46.9; D69.3; D69.49; D69.59; T45.1x5A - T45.1x5S; T66.XXXA - T66.XXXS.
- Immune Thrombocytopenia (ITP) — For treatment of ITP when both of the following criteria are met: Inadequate response or intolerance to prior therapy with corticosteroids, immunoglobulins, or splenectomy; and Untransfused platelet count at any point prior to the initiation of the requested medication is less than 30 x 10^9/L, or the member has a platelet count at time of diagnosis of between 30 x 10^9/L to 50 x 10^9/L with symptomatic bleeding (e.g., significant mucous membrane bleeding, gastroi [...]
- Hematopoietic Syndrome of Acute Radiation Syndrome (HS-ARS) — For treatment of hematopoietic syndrome of acute radiation syndrome (acute exposure to myelosuppressive doses of radiation).
- Myelodysplastic Syndromes (MDS) — For treatment of myelodysplastic syndromes.
2 Active Policies
CIGNA-0538 — Flow Cytometry - (0538)
AETNA-CPB-0768 — Romiplostim (Nplate)
Related Codes
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