Billing and Coding: Eculizumab, and Biosimilars: EPYSQLI®-eculizumab-aagh, and BKEMV™-eculizumab-aeeb

Eculizumab (and listed biosimilars) is covered for PNH (with flow cytometry confirmation plus hemolysis or thromboembolic MAVE), for aHUS as an initial 6–12 week trial when STEC-HUS is excluded and TTP is ruled out or plasma exchange failed, and for biopsy‑proven dense deposit disease with elevated sC5b‑9. Clinical records must document meningococcal vaccination (≥2 weeks before first dose) or a justification for immediate therapy, and dosing/frequency must conform to the FDA label or recognized compendia; deviations or lack of required documentation may result in denial or case-by-case review.

"Eculizumab is covered for treatment of paroxysmal nocturnal hemoglobinuria (PNH) when flow cytometry confirms PNH and there is either evidence of clinically significant hemolysis or a documented hi..."

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