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ICD-10-CM E80.20, Unspecified porphyria | No Prior Auth

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`E80.20`, Unspecified porphyria

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Key Coverage Criteria

Initial therapy with Givlaari is medically necessary for adults with acute hepatic porphyria (AHP) when: diagnosis of AHP is established; and the patient has active disease defined by at least 2 porphyria attacks in the past 6 months, OR patient is on prophylactic hemin with documented baseline hemin requirements and attack history; and patient has not had a liver transplant; and patient will not receive concomitant prophylactic hemin while on Givlaari; and treatment is prescribed by or in consu [...]

1 Active Policy

UHC-POL-givlaari-givosiran, Givlaari (Givosiran)

Related Codes

E80.0(1 policies)E80.1(1 policies)E80.21(1 policies)E80.29(1 policies)J0223(1 policies)

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