Billing and Coding: Guidance for Anti-Inhibitor Coagulant Complex (AICC) National Coverage Determination (NCD) 110.3
National · Effective Nov 24, 2022
1 active Medicare policy lists J7170, and 13 commercial payer policies list it. See each policy's status for the code and its official source. Listing a code is not a coverage decision: read each policy’s source for the requirements that apply.
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National · Effective Nov 24, 2022
13 policies from 12 payers
Summary of the payer’s published policy. Not a coverage determination — confirm with the payer before submitting.
Codes labeled “Inferred from policy title” are not listed in the policy document; Backwork attached them because the policy title names the drug.
| Policy | Effective | Status of J7170 |
|---|---|---|
| Hemlibra (emicizumab-kxwh) | Not recorded | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Hemlibra (emicizumab-kxwh) | Not recorded | Covered with conditionsInferred from policy title |
| Policy | Effective | Status of J7170 |
|---|---|---|
| HEMLIBRA | Not recorded | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Policy | Effective | Status of J7170 |
|---|---|---|
| EMICIZUMAB-KXWH: HEMLIBRA (J7170) (Retired 5/9/2019) | Not recorded | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Policy | Effective | Status of J7170 |
|---|---|---|
| Emicizumab Kxwh Hemlibra | Not recorded | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Policy | Effective | Status of J7170 |
|---|---|---|
| Hemlibra (emicizumab-kxwh) | Dec 1, 2025 | Prior auth requiredInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Policy | Effective | Status of J7170 |
|---|---|---|
| Emicizumab-kxwh (Hemlibra); CP.PHAR.370 | Not recorded | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Policy | Effective | Status of J7170 |
|---|---|---|
| Hemophilia Products - Congenital Factor VIII (Hemophilia A) with or without inhibitors: Hemlibra | Not recorded | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Policy | Effective | Status of J7170 |
|---|---|---|
| 00614 emicizumab (Hemlibra) | Not recorded | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Policy | Effective | Status of J7170 |
|---|---|---|
| Hemlibra (emicizumab-kxwh) | Not recorded | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Policy | Effective | Status of J7170 |
|---|---|---|
| Clotting Factors, Coagulant Blood Products, & Other Hemostatics | Jan 1, 2026 | Covered |
| Policy | Effective | Status of J7170 |
|---|---|---|
| Clotting Factors, Coagulant Blood Products, & Other Hemostatics | Jan 1, 2026 | Covered |
| Policy | Effective | Status of J7170 |
|---|---|---|
| Clotting Factors, Coagulant Blood Products, & Other Hemostatics | Jan 1, 2026 | Covered |