J1411 — Injection, etranacogene dezaparvovec-drlb, per therapeutic dose
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation 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.
- Documentation of patient age (≥18 years).
Key Coverage Criteria
- 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
- Etranacogene dezaparvovec-drlb is consideredmedically necessaryin individuals who meetallof the following criteria:
- Diagnosis of hemophilia B;and
- Age 18 years or older;and
9 Active Policies
ANTHEM-MED.00135 — MED.00135 Gene Therapy for Hemophilia
UHC-POL-gene-therapies-hemophilia — Gene Therapies for Hemophilia B
UMR-POL-UMR-gene-therapies-hemophilia — Gene Therapies for Hemophilia B
SUREST-POL-SUREST-gene-therapies-hemophilia — Gene Therapies for Hemophilia B
BCBSIL-RX501.151 — Etranacogene dezaparvovec-drlb
Related Codes
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