This version of the policy will become effective 01/01/2020.
The policy was updated to communicate coverage criteria, for sildenafil (Revatio®), intravenous infusion for pulmonary arterial hypertension (PAH) consistent with the US Food and Drug Administration (FDA) labeling.
The following HCPCS codes have been added to this policy to represent sildenafil (Revatio®) IV injection:
C9399 Unclassified drugs or biologicals
J3490 Unclassified drugs
Dosing and frequency requirements were added for all the agents to Attachment A of this policy.
I27.0 Primary pulmonary hypertension
I27.20 Pulmonary hypertension, unspecified
I27.21 Secondary pulmonary arterial hypertension
I27.22 Pulmonary hypertension due to left heart disease
I27.23 Pulmonary hypertension due to lung diseases and hypoxia
I27.24 Chronic thromboembolic pulmonary hypertension
I27.29 Other secondary pulmonary hypertension
I27.83 Eisenmenger's syndrome
P29.30 Pulmonary hypertension of newborn