This version of the policy will become effective 03/02/2020.
The following criteria have been added to this policy:
When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
FOR Alpha 1-Antitrypsin Therapy COVERAGE BOTH DIAGNOSES ARE REQUIRED
E88.01 Alpha-1-antitrypsin deficiency
AND THE FOLLOWING:
J43.1 Panlobular emphysema
The following HCPCS code has been deleted from this policy:
S9346 Home infusion therapy, alpha-1-proteinase inhibitor (e.g., Prolastin); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
The following ICD-10 CM code has been added to this policy:
J43.9 Emphysema, unspecified
Note: on 01/14/2020 the following revisions were made to this policy in Notification:
ICD-10 code will NOT be added to this policy: J43.9 Emphysema, unspecified. This unspecified code will not be added and the more specific ICD-10 codes per policy criteria remain.
A billing requirement statement has been added to clarify, that for alpha 1-antitrypsin therapy (e.g., Prolastin-C®, Aralast NP™, Glassia™, Zemaira™), both of the following diagnoses are required:
E88.01 Alpha-1-antitrypsin deficiency AND J43.1 panlobular emphysema