IBC Medical Policies

Coverage Guidelines

Services that require precertification for Independence Commercial Members (Effective 04/01/2019)

Services that require precertification

As of January 1, 2019, this list applies to all Independence Blue Cross HMO, PPO, and POS products, including Flex products. This list was revised effective April 1, 2019 to incorporate updated medical codes. For Federal Employee Program (FEP) precertification requirements, please see the separate

FEP precertification list

This applies to services performed on an elective, nonemergency basis

Because a service or item is subject to precertification, it does not guarantee coverage. The terms and conditions of your benefit plan must be reviewed to determine if any of these services or items are excluded.

You can find additional information regarding preapproval/precertification, member cost-sharing and prescription drug coverage on the Independence

Preapproval/Precertification Requirements, Member Cost-Sharing, and Prescription Drug Formulary Lists

page.

All home-care services (including infusion therapy in the home)

Inpatient services

Acute rehabilitation admissions

Elective surgical and nonsurgical inpatient admissions

Inpatient hospice admissions

Long term acute care (LTAC) facility admissions

Skilled nursing facility admissions

Cardiology procedures

Precertification is performed by AIM Specialty Health®, an independent company. To access the complete list of AIM

Clinical Appropriateness Guidelines for Cardiology and Arterial Ultrasound

, click

here

Arterial ultrasound

Diagnostic coronary angiography

Percutaneous coronary intervention

Any procedure, device, or service that may potentially be considered experimental or investigational including:

New emerging technology/procedures, as well as existing technology and procedures applied for new uses and treatments

Procedures

Bronchial thermoplasty
31660, 31661

Cochlear implant surgery and associated supplies/bone-anchored (osseointegrated) hearing aids, implantable bone conduction hearing aids
69714, 69715, 69717, 69718, 69930, L8619, L8627, L8628, L8629, L8690, L8691, L8692, L8693

Obesity surgery
43644, 43645, 43659, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43886, 43887, 43888, 43999

Uvulopalatopharyngoplasty (UPPP)
42145

Musculoskeletal Procedures

Precertification is performed by AIM Specialty Health®, an independent company. To access the complete list of

AIM Clinical Appropriateness Guidelines for Musculoskeletal

, click

here

Bone graft substitutes and bone morphogenetic proteins for spine surgery

Cervical decompression with or without fusion cervical disc arthroplasty

Hip arthroplasty

Hip arthroscopy and open procedures

Knee arthroplasty

Knee arthroscopy and open procedures

Lumbar disc arthroplasty

Lumbar discectomy, foraminotomy, and laminotomy

Lumbar fusion and treatment of spinal deformity (including scoliosis and kyphosis)

Lumbar laminectomy

Meniscal allograft transplantation of the knee

Shoulder arthroplasty

Shoulder arthroscopy and open procedures

Treatment of osteochondral defects

Vertebroplasty/Kyphoplasty

Interventional pain management services

Precertification will be performed by AIM Specialty Health®,

an independent company

. To access the complete list of AIM Clinical Appropriateness Guidelines for Interventional Pain Management, click

here

Epidural Injection Procedures and Diagnostic Selective Nerve Root Blocks

Paravertebral Facet Injection/Nerve Block/Neurolysis

Regional Sympathetic Nerve Block

Sacroiliac joint injections

Implanted spinal cord stimulators

Reconstructive procedures and potentially cosmetic procedures

Blepharoplasty/ptosis repair
15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909

Bone graft, genioplasty and mentoplasty
21120, 21121, 21122, 21123

Breast Reconstruction
11920, 11921, 11922, 11970, 11971, 15271, 15272, 15777, 19350, 19355, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19380, 20926, Q4100, Q4107, Q4130, S2066, S2067, S2068

Breast Reduction
15877, 19318

Breast Augmentation/Mammoplasty
19324, 19325

Breast Mastopexy
19316

Insertion of Breast Implants
19340, 19342, 19396

Removal of Breast Implants
19328, 19330, 19370, 19371

Canthopexy/Canthoplasty
21280, 21282, 67950

Cervicoplasty
15819

Chemical peels
15788, 15789, 15792, 15793

Dermabrasion
15780, 15781, 15782, 15783

Excision of excessive skin and/or subcutaneous tissue
15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839

Gender reassignment surgery
11960, 19303, 19304, 53430, 54125, 54400, 54401, 54405, 54520, 54660, 54690, 55175, 55180, 57106, 57110, 58150, 58180, 58260, 58262, 58275, 58290, 58291, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720

Genetically and bio-engineered skin substitutes for wound care
Q4100, Q4101, Q4102, Q4103, Q4104, Q4105, Q4106, Q4107, Q4108, Q4110, Q4111, Q4113, Q4114, Q4115, Q4117, Q4118, Q4121, Q4122, Q4123, Q4124, Q4126, Q4127, Q4132, Q4133, Q4134, Q4135, Q4136, Q4137, Q4139, Q4140, Q4141, Q4145, Q4146, Q4147, Q4148, Q4149, Q4151, Q4152, Q4153, Q4154, Q4155, Q4156, Q4157, Q4158, Q4159, Q4160, Q4161, Q4162, Q4163, Q4164, Q4165, Q4166, Q4167, Q4168, Q4169, Q4170, Q4171, Q4173, Q4174, Q4175, Q4176, Q4177, Q4178, Q4179, Q4180, Q4181, Q4182

Hair transplant
15775, 15776

Injectable dermal fillers
11950, 11951, 11952, 11954, Q2026, Q2028

Keloid removal
13100, 13101, 13102, 13120, 13121, 13122, 13131, 13132, 13133, 13151, 13152, 13153, 14000, 14001, 14020, 14021, 14040, 14041, 14060, 14061, 14301, 14302, 15002, 15003, 15004, 15005, 15040, 15050, 15100, 15101, 15110, 15111, 15115, 15116, 15120, 15121, 15130, 15131, 15135, 15136, 15150, 15151, 15152, 15155, 15156, 15157, 15200, 15201, 15220, 15221, 15240, 15241, 15260, 15261, 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278, 15570, 15572, 15574, 15576, 15600, 15610, 15620, 15630, 15650, 15731, 15733, 15734, 15736, 15738, 15740, 15750, 15756, 15757, 15758, 15760, 15770, 15780, 15781, 15782, 15783, 15786, 15787, 31830

Lipectomy, liposuction, or any other excess fat-removal procedure
15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15876, 15877, 15878, 15879

Otoplasty
13151, 13152, 13153, 14060, 14061, 15260, 15261, 21235, 69300, 69399

Rhinoplasty
30400, 30410, 30420, 30430, 30435, 30450

Rhytidectomy
15824, 15825, 15826, 15828, 15829, 15838, 15839, 15876

Scar revision
13100, 13101, 13102, 13120, 13121, 13122, 13131, 13132, 13133, 13151, 13152, 13153, 14000, 14001, 14020, 14021, 14040, 14041, 14060, 14061, 14301, 14302, 15002, 15003, 15004, 15005, 15040, 15050, 15100, 15101, 15110, 15111, 15115, 15116, 15120, 15121, 15130, 15131, 15135, 15136, 15150, 15151, 15152, 15155, 15156, 15157, 15200, 15201, 15220, 15221, 15240, 15241, 15260, 15261, 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278, 15570, 15572, 15574, 15576, 15600, 15610, 15620, 15630, 15650, 15731, 15733, 15734, 15736, 15738, 15740, 15750, 15756, 15757, 15758, 15760, 15770, 15780, 15781, 15782, 15783, 15786, 15787, 31830

Skin closures
13100, 13101, 13102, 13120, 13121, 13122, 13131, 13132, 13133, 13151, 13152, 13153, 14000, 14001, 14020, 14021, 14040, 14041, 14060, 14061, 14301, 14302, 15002, 15003, 15004, 15005, 15040, 15050, 15100, 15101, 15110, 15111, 15115, 15116, 15120, 15121, 15130, 15131, 15135, 15136, 15150, 15151, 15152, 15155, 15156, 15157, 15200, 15201, 15220, 15221, 15240, 15241, 15260, 15261, 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278, 15570, 15572, 15574, 15576, 15600, 15610, 15620, 15630, 15650, 15731, 15733, 15734, 15736, 15738, 15740, 15750, 15756, 15757, 15758, 15760, 15770

Surgery for varicose veins, including perforators and sclerotherapy
36465, 36466, 36470, 36471, 36475, 36476, 36478, 36479, 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, 37799

Elective (nonemergency) ground, air, and sea ambulance transportation

A0140, A0426, A0428, A0430,

A0431

A0434,

S9960, S9961

Outpatient private-duty nursing

S9123, S9124

Day rehabilitation programs

0931, 0932

Outpatient radiation therapy

Precertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore), an independent company. To access the eviCore Radiation Therapy Clinical Guidelines, click

here

and scroll down to

View more for health plan specific radiation therapy guidelines

and select

Independence

from the list.

Radiology

Precertification is performed by AIM Specialty Health®, an independent company. To access the complete list of AIM Specialty Health Diagnostic Imaging Utilization Management Clinical Guidelines, click

here

Echocardiography services

Testing transthoracic echocardiography (TTE)

Stress echocardiography (SE)

Transesophageal echocardiography (TE)

Nuclear cardiology

PET scans

Prosthetics/orthoses including:

Custom ankle-foot orthoses
L1900, L1904, L1907, L1920, L1940, L1945, L1950, L1960, L1970, L1980, L1990, L2106, L2108, L4631

Custom knee-ankle-foot orthoses
L2000, L2005, L2010, L2020, L2030, L2034, L2036, L2037, L2038, L2126, L2128

Custom knee braces
L1834, L1840, L1844, L1846, L1860

Custom limb prosthetics including accessories/components
L5010, L5020, L5050, L5060, L5100, L5105, L5150, L5160, L5200, L5210, L5220, L5230, L5250, L5270, L5280, L5301, L5312, L5321, L5331, L5341, L5510, L5520, L5530, L5535, L5540, L5560, L5570, L5580, L5585, L5590, L5595, L5600, L5610, L5611, L5613, L5614, L5616, L5617, L5618, L5620, L5622, L5624, L5626, L5628, L5629, L5630, L5631, L5632, L5634, L5636, L5637, L5638, L5639, L5640, L5642, L5643, L5644, L5645, L5646, L5647, L5648, L5649, L5650, L5651, L5652, L5653, L5654, L5655, L5656, L5658, L5661, L5665, L5666, L5668, L5670, L5671, L5672, L5673, L5676, L5677, L5678, L5679, L5680, L5681, L5682, L5683, L5684, L5685, L5686, L5688, L5690, L5692, L5694, L5695, L5696, L5697, L5698, L5699, L5700, L5701, L5702, L5703, L5704, L5705, L5706, L5707, L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780, L5781, L5782, L5785, L5790, L5795, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, L5845, L5848, L5850, L5855, L5856, L5857, L5858, L5859, L5910, L5920, L5925, L5930, L5940, L5950, L5960, L5962, L5964, L5966, L5968, L5970, L5971, L5972, L5973, L5974, L5975, L5976, L5978, L5979, L5980, L5981, L5982, L5984, L5985, L5986, L5987, L5988, L5990, L5999, L6000, L6010, L6020, L6050, L6055, L6100, L6110, L6120, L6130, L6320, L6350, L6360, L6370, L6400, L6450, L6500, L6550, L6570, L6580, L6582, L6584, L6586, L6588, L6590, L6600, L6605, L6610, L6611, L6615, L6616, L6620, L6621, L6623, L6624, L6625, L6628, L6629, L6630, L6632, L6635, L6637, L6638, L6640, L6641, L6642, L6645, L6646, L6647, L6648, L6650, L6655, L6660, L6665, L6670, L6672, L6675, L6676, L6677, L6680, L6682, L6684, L6686, L6687, L6688, L6689, L6690, L6691, L6692, L6693, L6694, L6695, L6696, L6697, L6698, L6703, L6704, L6706, L6707, L6708, L6709, L6711, L6712, L6713, L6714, L6715, L6721, L6722, L6805, L6810, L6880, L6881, L6882, L6883, L6884, L6885, L6890, L6895, L6900, L6905, L6910, L6915, L6920, L6925, L6930, L6935, L6940, L6945, L6950, L6955, L6960, L6965, L6970, L6975, L7007, L7008, L7009, L7040, L7045, L7170, L7180, L7181, L7185, L7186, L7190, L7191, L7260, L7400, L7401, L7402, L7403, L7404, L7405, L7499

Selected durable medical equipment (DME)

Bone growth stimulators
E0747, E0760

Bone growth stimulator, electrical, noninvasive, spinal
Precertification is performed by AIM Specialty Health®, an independent company. To access the complete list of AIM Clinical Appropriateness Guidelines for Musculoskeletal, click here.

Bone-anchored (osseointegrated) hearing aids
L8690, L8691, L8692, L8693, L8694

Continuous positive airway pressure (CPAP) devices, bi-level (Bi-PAP) devices, and all supplies
Precertification is performed by AIM Specialty Health®, an independent company. To access the complete list of AIM Specialty Health Sleep Disorder Management Diagnostic & Treatment Guidelines, click here.

Dynamic adjustable and static progressive stretching devices (excludes CPMs)
E1800, E1802, E1805, E1810, E1812, E1825, E1830

Electric, power, and motorized wheelchairs including custom accessories
E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1010, E1012, E1239, E2291, E2292, E2293, E2294 E2310, E2311, E2312, E2313, E2321, E2322, E2323, E2324, E2325, E2326, E2327, E2328, E2329, E2330, E2331 E2340, E2341, E2342, E2343, E2351, E2373, E2377, E2603, E2604, E2605, E2606, E2607, E2608, E2609, E2613 E2614, E2615, E2616, E2617, E2620, E2621, E2622, E2623, E2624, E2625, E2626, E2627, E2628, E2629, E2630 K0010, K0011, K0012, K0013, K0014, K0056, K0108, K0813, K0814, K0815, K0816, K0820, K0821, K0822, K0823 K0824, K0825, K0826, K0827, K0828, K0829, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843 K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862 K0863, K0864, K0890, K0891, K0898

External defibrillator and associated accessories
E0617, K0606

High frequency chest wall oscillation generator system
E0483

Insulin pumps
E0784, S1034

Manual wheelchairs with the exception of those that are rented
E0958, E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1010, E1012, E1031, E1037, E1038, E1039 E1050, E1060, E1070, E1083, E1084, E1085, E1086, E1087, E1088, E1089, E1090, E1092, E1093, E1100, E1110 E1130, E1140, E1150, E1160, E1161, E1170, E1171, E1172, E1180, E1190, E1195, E1200, E1220, E1221, E1222 E1223, E1224, E1229, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, E1240, E1250, E1260, E1270 E1280, E1285, E1290, E1295, E2291, E2292, E2293, E2294, E2295, E2603, E2604, E2605, E2606, E2607, E2608 E2609, E2613, E2614, E2615, E2616, E2617, E2620, E2621, E2622, E2623, E2624, E2625, E2626, E2627, E2628 E2629, E2630, K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0008, K0009, K0108

Negative pressure wound therapy
A6550, A9272, E2402, K0743, K0744, K0745, K0746

Neuromuscular stimulators
E0744, E0745, E0764, E0770

Power operated vehicles (POV)
E1230, K0800, K0801, K0802, K0812

Pressure reducing support surfaces including:

Air fluidized bed
E0194

Non powered advanced pressure reducing mattress
E0371, E0373

Powered air flotation bed (low air loss therapy)
E0193, E0372

Powered pressure reducing mattress
E0277

Push rim activated power assist devices
E0986

Repair or replacement of all DME items, as well as orthoses and prosthetics that require precertification
E2368, E2369, E2370, E2374, E2375, E2376

Speech generating devices
E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2599, V5336

Medical foods

B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, S9433, S9434, S9435

Hyperbaric oxygen therapy

0413, G0277

Proton beam therapy

Precertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore), an independent company. To access the eviCore Radiation Therapy Clinical Guidelines, click

here

and scroll down to

View more for health plan specific radiation therapy guidelines

and select

Independence

from the list.

Sleep studies (facility based)

Precertification is performed by AIM Specialty Health®, an independent company. To access the complete list of AIM Specialty Health Sleep Disorder Management Diagnostic & Treatment Guidelines, click

here.

Sleep studies (home-based)

Precertification will be performed by AIM Specialty Health®

, an independent company

. To access the complete list of AIM Specialty Health Sleep Disorder Management Diagnostic & Treatment Guidelines, click

here.

All transplant procedures, with the exception of corneal transplants

15775, 15776, 27415, 27416, 29866, 29867, 32851, 32852, 32853, 32854, 33935, 33945, 38205, 38206, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230, 38232, 38240, 38241, 38242, 38243, 44133, 44135, 44136, 44137, 47135, 47140, 47141, 47142, 47399, 48160, 48554, 48556, 50320, 50340, 50360, 50365, 50370, 50380, 50547, G0341, G0342, G0343, S2053, S2054, S2060, S2061, S2065, S2103, S2140, S2142, S2150

Mental health/serious mental illness/substance abuse

Precertification review for these services is provided by Magellan Healthcare, Inc., an independent company.

Mental health and serious mental illness treatment (inpatient/partial hospitalization programs/intensive outpatient programs)

Repetitive transcranial magnetic stimulation (RTMS)

Substance abuse treatment (inpatient/partial hospitalization programs/intensive outpatient programs)

Autism spectrum disorders

Applied behavioral analysis
Precertification review for this service is provided by Magellan Healthcare, Inc., an independent company.

Genetic and genomic tests requiring precertification

Precertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore), an independent company. To access the eviCore Lab Management details, click

here

and scroll down

to select the appropriate Independence document under

CPT Codes

Resources

, or

Clinical Guidelines

The following list is a guide to the types of genetic and genomic tests that require precertification. Due to the volume of tests, it is not possible to list each test separately. To determine if a test requires precertification, please see the complete procedure code list for details.

Please note

: precertification of genetic and genomic tests applies to commercial members only.

Hereditary cancer syndromes

BRCA gene testing (breast and ovarian cancer syndrome)

Lynch syndrome gene testing

Familial adenomatous polyposis gene testing

PTEN gene testing (Cowden syndrome)

General cancer type panels (such as colon, breast, or neuroendocrine cancers)

Hereditary heart diseases

Long QT syndrome gene testing

Aortic dilation or aneurysm syndrome testing (includes Marfan syndrome)

Other full gene analysis testing

Cystic fibrosis full gene sequencing and deletion/duplication analysis

PMP22 full gene sequencing and deletion/duplication analysis (Charcot-Marie-Tooth, hereditary neuropathy)

Tests for many genetic disorders simultaneously

Expanded carrier screening panels (such as Carrier Status DNA Insight®, Counsyl Family Prep Screen, Pan-Ethnic Carrier Screening)

Hearing loss panels

Intellectual disability panels

Noonan spectrum disorders panels

Specialty oncology tests

Cancer gene expression or protein signature tests (such as OncotypeDX®, MammaPrint®, Afirma®, Prosigna®, HeproDX™)

Tumor molecular profiling (such as FoundationOne®, neoTYPE™, OncoPlexDx®, and many others)

Tissue of origin testing (for cancer of unknown primary)

PCA3 testing for prostate cancer

Pharmacogenomic tests

Cytochrome P450 metabolism gene testing (CYP2D6, CYP2C9, CYP2C19)

Specialized drug response gene panels (such as Assurex GeneSight®, GeneTrait, Genecept®, Millennium PGT^SM)

Warfarin response testing

MGMT methylation analysis for glioblastoma

Other specialty tests

Coronary artery disease risk testing (such as CorusCAD®, CardioIQ®, APOE, ACE, KIF6)

Heart disease risk testing (such as CorusCAD®, CardioIQ®, APOE, ACE, KIF6, MTHFR)

Genome-wide tests

Microarray studies

Whole exome testing

Whole genome testing

Mitochondrial genome or nuclear testing

ANY genetic test for more than one gene or condition (often includes words like “panel” or “comprehensive” in the name)

ANY genetic test that will be billed with a non-specific procedure code

Billed with CPT® codes 81400-81408

Billed with an unlisted code: 81479, 81599, 84999

Specialty drugs requiring precertification

All listed brands and their generic equivalents or biosimilars require precertification. This list is subject to change.

Antineoplastic agents

Abraxane® - J9264
Adcetris® - J9042
Alimta® - J9305
Avastin® - C9257 and J9035 (Note: Opthalmologic use of Avastin does not require precertification. Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
Azedra - C9408
Azedra Dosimetric - C9407
Beleodaq® - J9032
Blincyto™ - J9039
Cyramza® - J9308
Darzalex™ - J9145
Elzonris™ - J3590 and C9399
Erbitux® - J9055
Erwinaze® - J9019
Folotyn® - J9307
Halaven® - J9179
Herceptin® - J3490 (Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
Herzuma - J3490
Imlygic™ - J9325
Istodax® - J9315
Jevtana® - J9043
Kadcyla® - J9354
Kyprolis® - J9047
Lumoxiti™ - J3590 and C9045
Mvasi™ - Q5107 (Note: Opthalmologic use of Mvasi does not require precertification.)
Ogivri - J3490
Ontruzant - J3490
Pemfexy - J3490
Perjeta® - J9306
Poteligeo® - J3590 and C9038
Provenge® - Q2043
Rituxan® - J9312 (Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
Rituxan Hycela™ - J9311
sacituzumab govitecan (pending FDA approval) - J3490
Truxima™ - J3590 and C9399
Xofigo®* - A9606
Yervoy™ - J9228
Zevalin®* - A9543

Precertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore), an independent company. To access the eviCore Radiation Therapy Clinical Guidelines, click

here

and scroll down to

View more for health plan specific radiation therapy guidelines

and select

Independence

from the list.

Anti PD-1/PD-L1 human monoclonal antibodies

All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.

Bavencio® - J9023
Imfinzi™ - J9173
Keytruda™ - J9271
Libtayo® - J9999 and C9044
Opdivo® - J9299
Tecentriq™ - J9022

Bone-modifying agents

Prolia® - J0897
Xgeva® - J0897

tulinum toxin agents

Botox® - J0585

Cardiovascular agents

Flolan® - J1325
Remodulin® - J3285
Veletri® - J1325

hemotherapy-induced nausea and vomiting (CINV) agents

Sustol® - J1627

himeric antigen receptor (CAR-T) therapies

Kymriah™ - Q2042
Yescarta™ - Q2041

Colony stimulating factors

Fulphila™ - Q5108
Neulasta® - J2505 (Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
Neulasta Onpro™ - J2505
Nivestym™ - Q5110
Udenyca™ - Q5111

Endocrine/metabolic agents

H.P. Acthar® - J0800
Lutathera®* - A9513 and A9699
Makena® - J1726 and J1729
Sandostatin® LAR - J2353
Somatuline® depot - J1930

Precertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore), an independent company. To access the eviCore Radiation Therapy Clinical Guidelines, click

here

and scroll down to

View more for health plan specific radiation therapy guidelines

and select

Independence

from the list.

Enzyme replacement agents

Adagen® - J2504
Aldurazyme® - J1931
Brineura™ - J0567
Cerezyme® - J1786
Elaprase® - J1743
Elelyso® - J3060
Fabrazyme® - J0180
Kanuma® - J2840
Lumizyme® - J0221
Mepsevii™ - J3397
Naglazyme® - J1458
Replagal® (pending FDA approval) - J3490
Revcovi™ - J3590 and C9399
Vimizim™ - J1322
VPRIV® - J3385

Gene Therapy

Luxturna™ - J3398
Zolgensma® (pending FDA approval) - J3490

Hemophilia/Coagulation factors

Advate - J7192
Adynovate - J7207
Afstyla - J7210
Alphanate - J7186
Alphanine SD - J7193
Alprolix - J7201
Autoplex T - J7198
Bebulin VH - J7194
Bebulin - J7194
Benefix - J7195
Bioclate - J7192
Coagadex - J7175
Corifact - J7180
Eloctate - J7205
Feiba NF - J7198
Feiba VH - J7198
Fibryga - J7177
Fibryna - J7178
Helixate FS - J7192
Hemlibra - J7170
Hemofil-M - J7190
Humate-P - J7187
Hyate-C - J7191
Idelvion - J7202
Ixinity - J7199
Jivi® - J7199 and C9141
Koate-DV I- J7190
Kogenate FS - J7192
Kovaltry - J7207 and J7211
Monarc - J7190
Monoclate-P - J7190
Mononine - J7193
Novoeight - J7182
Novoseven RT - J7189
Novoseven - J7189
Nuwiq - J7209
Obizur - J7188
Profilnine SD - J7194
Proplex T - J7194
Rebinyn - J7203
Recombinate - J7192
Refacto - J7192
RiaSTAP - J7178
Rixubis - J7195 and J7200
Tretten - J7181
Vonvendi - J7179 and J7199
Wilate - J7183
Xyntha - J7185

Hyaluronate acid products

Cingal (pending FDA approval) - J3490
Durolane® - J7318
Euflexxa™ - J7323
Gel-One® - J7326
Gelsyn-3™ - J7328
GenVisc 850® - J7320
Hyalgan® - J7321
Hymovis® - J7322
Monovisc® - J7327
Supartz® - J7321
TriVisc™ - J7329
VISCO-3® - J3490

Immunological agents

Actemra® - J3262
Benlysta® - J0490
Entyvio™ - J3380
Ilumya™ - J3245
Inflectra™ - Q5103
Ixifi™ - Q5109
Orencia® - J0129
Remicade® - J1745 (Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
Renflexis™ - Q5104
Simponi® Aria - J1602
Stelara® - J3357 and J3358

Intravenous Immune Globulin/Subcutaneous Immune Globulin (IVIG/SCIG)

Intravenous Immune Globulin (IVIG)

Bivigam - J1556
Carimune - J1566
Flebogamma - J1572
Flebogamma-Dif - J1572
Gammagard - J1569
Gammagard Liquid - J1569
Gammagard S/D - J1566
Gammaked - J1561
Gammaplex - J1557
Gamunex-C - J1561
Octagam - J1568
Panzyga - J1599
Privigen - J1459

Subcutaneous Immune Globulin (SCIG)

Cutaquig - J3490
Cuvitru - J1555
Hizentra - J1559
Hyqvia - J1575

Multiple sclerosis agents

Lemtrada® - J0202
Ocrevus™ - J2350
Tysabri® - J2323

Respiratory agents

Cinqair® - J2786
Fasenra™ - J0517
Nucala® - J2182
Synagis® - 90378
Xolair® - J2357

Respiratory enzymes (Alpha-1 antitrypsin)

Aralast - J0256
Glassia™ - J0257
Prolastin® - J0256
Zemaira® - J0256

Miscellaneous therapeutic agents

Ampligen® (pending FDA approval) - J3490
Crysvita - J0584
Exenatide sustained-release ITCA 650 (pending FDA approval) - J3490
Exondys-51™ - J1428
Ilaris - J0638
Gamifant® - J3590 and C9399
Krystexxa - J2507
Onpattro - J3590 and C9036
Radicava - J1301
ravulizumab - J3490
Remune (pending FDA approval) - J3490
Soliris® - J1300 (Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
Soliris biosimilar (pending FDA approval) - J3590 and C9399
Spinraza - J2326
Sylvant™ - J2860
Trogarzo - J1746
Ultomiris™ - J3590 and C9399

Revisions

April 1, 2019

The following revisions were incorporated into the April 1, 2019 update.

Additions

: codes added

Elective (nonemergency) ground, air, and sea ambulance transportation

A0431, S9960, S9961

Anti PD-1/PD-L1 human monoclonal antibodies

Libtayo® - C9044

Antineoplastic agents

Lumoxiti™ - C9045

Colony stimulating factors

Udenyca™ - Q5111

Hemophilia/Coagulation factors

Jivi® - C9141

Deletions

: codes removed

Reconstructive procedures and potentially cosmetic procedures

Surgery for varicose veins, including perforators and sclerotherapy - 36473, 36474

Independence Blue Cross offers products through its subsidiaries Independence Hospital Indemnity Plan, Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association.

Issued on - 04/18/2019