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HCPCS/CPT C9172, Injection, fidanacogene elaparvovec-dzkt, per therapeutic dose | No Prior Auth

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`C9172`, Injection, fidanacogene elaparvovec-dzkt, per therapeutic dose

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Key Coverage Criteria

Etranacogene dezaparvovec-drlb is consideredmedically necessaryin individuals who meetallof the following criteria:
Diagnosis of hemophilia B;and
Age 18 years or older;and
Baseline factor IX level is less than 1 international unit (IU)/deciliter (dL) (or 1% endogenous factor IX);and
No contraindications to infusion (if any of the following are present, treatment is contraindicated):Active infection;orImmunosuppressive disorder;orLiver cirrhosis;orActive hepatitis B or C;orAlanine transaminase (ALT) greater than 3 times the upper limit of normal;orBilirubin greater than 3 times the upper limit of normal;orAlkaline phosphatase greater than 3 times the upper limit of normal;orInternational normalized ratio (INR) greater than1.4.;orPrior infusion of gene therapy for hemophilia [...]
Active infection;or

1 Active Policy

ANTHEM-MED.00135, Gene Therapy for Hemophilia

Related Codes

00135(1 policies)C9399(1 policies)J1411(1 policies)J1412(1 policies)J1414(1 policies)J3490(1 policies)J3590(1 policies)

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