New clinical edits going into effect on May 28
We value the care you provide our members and strive to reimburse you accurately and fairly for that care. Thoughtful implementation of clinical edits supports this goal, while allowing us to process your claims more efficiently.
On May 28, we’ll implement the new clinical edits listed below:
Upcoming clinical edits
Daratumumab Injection Code on Claim without Approved Indication
Provider Type: Professional | Product: Commercial, Individual / ACA, Medicare
The FDA provides guidance around approved indications or approved off-label indications for use of defined drugs and biologicals. These approved indications or off-label indications identify conditions or diagnoses appropriate for use with this drug. A denial will be applied to claims reported for J9144 (Injection, daratumumab, 10 mg and hyaluronidase-fihj) when billed and an FDA approved indication or an approved off-labeled indication is not present on the claim. FDA approved codes: C90.00-C90.32 and E85.81.
Ocrelizumab Injection Code Billed More Than Twice Per Month
Provider Type: Professional and Facility | Product: All products
The FDA provides guidance around approved indications for use of defined drugs and biologicals. These approved indications identify timing or dosing requirements appropriate for use with this drug for defined treatments or diagnoses. In alignment with the dosing instructions for J2350 (Injection, ocrelizumab, 1 mg), two 300-mg infusions should occur two weeks apart. To apply accurate dosing criteria, a denial will apply to J2350 when billed by any provider more than two visits per month and the diagnosis is relapsing or primary progressive multiple sclerosis.
Bevacizumab and Biosimilars Billed without Approved Indication
Provider Type: Professional | Product: Commercial, Individual / ACA, Medicare
The FDA provides guidance around approved indications or approved off-label indications for use of defined drugs and biologicals. These approved indications or off-label indications identify conditions or diagnoses appropriate for use with this drug. A denial will be applied to claims reported for the following codes when billed and an FDA approved indication or an approved off-labeled indication is not present on the claim:
- J9035 – Injection, bevacizumab, 10 mg
- Q5107 – Injection bevacizumab-AWWB, biosimilar, (MVASI), 10 mg
- Q5118 – Injection, bevacizumab-BVZR, biosimilar, (ZIRABEV), 10 mg
- Q5126 – Injection, bevacizumab-MALY, biosimilar, (ALYMSYS), 10 mg
Learn more
Additional information on our clinical edits policy is available online. You can also see recent and upcoming clinical edits for professional claims in the PDF linked below. Bookmark it in your internet browser to ensure you always have the latest updates.