Covered without prior authorization (high confidence)
Documentation Required
Documentation that the requested medication will be used to mobilize hematopoietic stem cells for collection prior to transplantation (documentation of planned autologous transplantation or intent to collect for transplant).
Documentation of pregnancy/lactation status and any counseling regarding risks to pregnant/nursing members.
Clinical notes addressing prior mobilization attempts and rationale for plerixafor (particularly relevant for poor mobilizers or re-mobilization scenarios), if applicable.
Relevant laboratory data as applicable (e.g., renal function/creatinine clearance for dose adjustment).
Key Coverage Criteria
Aetna considers plerixafor (Mozobil or generic plerixafor) injection medically necessary when all of the following criteria are met: The requested medicaton will be used to mobilize hematopoietic stem cells for collection prior to transplantation; and The requested medication will be administered after the member has received a granulocyte-colony stimulating factor (G-CSF) (e.g., filgrastim) or chemo-mobilization; and The requested medication will not be used beyond 4 consecutive days or after c [...]
Continuation of plerixafor (Mozobil) injection therapy is medically necessary for all members (including new members) who meet all initial medical necessity selection criteria.
FDA-approved indication (background): Mozobil is indicated in combination with granulocyte-colony stimulating factor (G-CSF) to mobilize hematopoietic stem cells (HSCs) to the peripheral blood for collection and subsequent autologous transplantation in patients with non-Hodgkin’s lymphoma or multiple myeloma.
HCPCS code covered if selection criteria are met: J2562 Injection, plerixafor, 1 mg [Mozobil].
ICD-10 codes covered if selection criteria are met: C82.00 - C82.99; C84.00 - C84.49; C84.a0 - C84.99; C85.10 - C85.99; C86.0 - C86.6; C91.40 - C91.42; C96.0 - C96.4; C96.a - C96.9; Other malignant neoplasms of lymphoid and histiocytic tissue; C83.00 - C83.99; C84.60 - C84.79; C88.4; C88.8 - C90.32 (Malignant immunoproliferative diseases and multiple myeloma and malignant plasma cell neoplasms).
Compendial use listed: Hematopoietic cell transplantation.
When billing, use applicable CPT/HCPCS codes (e.g., J2562 for plerixafor 1 mg) and the appropriate ICD-10 diagnosis code from the covered list corresponding to the treated hematologic malignancy.
Documentation that the requested medication will be administered after the member has received a granulocyte-colony stimulating factor (G-CSF) (e.g., filgrastim) or after chemo-mobilization (dates and agents used for prior G-CSF or chemo-mobilization).