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ICD-10-CM Z16.33, Resistance to antiviral drug(s) | No Prior Auth

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`Z16.33`, Resistance to antiviral drug(s)

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Provider attestation that the patient has multi-drug resistant HIV-1 infection (required for initial therapy)
Provider confirmation/documentation that the patient has been prescribed an optimized background antiretroviral regimen containing at least one antiretroviral agent that demonstrates full viral sensitivity/susceptibility (required for initial and continuation therapy)
For continuation therapy: documentation that the patient has previously received Trogarzo (ibalizumab-uiyk)
For continuation therapy: provider confirmation/documentation that the patient has achieved a clinically significant viral response to Trogarzo therapy (e.g., documented viral load response)

Key Coverage Criteria

Trogarzo (ibalizumab-uiyk) is proven and medically necessary for the treatment of multi-drug resistant human immunodeficiency virus (HIV) in patients who meet all of the following criteria:
For initial therapy, all of the following:
Diagnosis of HIV-1 infection
Provider attestation that the patient has multi-drug resistant HIV-1 infection
Provider confirms that the patient has been prescribed an optimized background antiretroviral regimen, containing at least one antiretroviral agent that demonstrates full viral sensitivity/susceptibility
Trogarzo (ibalizumab-uiyk) initial and maintenance dosing is in accordance with the US Food and Drug Administration prescribing information

1 Active Policy

UHC-POL-trogarzo-ibalizumab-uiyk, Trogarzo (Ibalizumab-Uiyk)

Related Codes

B20(1 policies)J1746(1 policies)Z21(1 policies)

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Documentation that Trogarzo dosing (initial and maintenance) follows the US FDA prescribing information

Member-specific benefit plan document should be consulted (policy states coverage decisions must reference the member specific benefit plan document and applicable laws/mandates)