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 J7204, and 7 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
7 policies from 7 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 J7204 |
|---|---|---|
| Factor VIII (e.g., Advate, Adynovate, Afstyla, Alphanate, Altuviiio, Eloctate, Esperoct, Jivi, Hemofil-M, Humate-P, Koate, Kovaltry, Novoeight, Nuwiq, Obizur, Recombinate, Wilate, Xyntha) | 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 J7204 |
|---|---|---|
| Advate, Adynovate, Afstyla, Altuviiio, Eloctate, Esperoct, Jivi, Kogenate FS, Kovaltry, Obizur, Novoeight, Nuwiq, Recombinate, Xyntha (antihemophilic factor [recombinant]) Hemofil M, Koate-DVI (antihemophilic factor [plasma deEffective 08/01/2024 - 07/31/2025 | Aug 1, 2024 | Prior auth requiredInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Policy | Effective | Status of J7204 |
|---|---|---|
| Hemophilia Products – Factor VIII (Hemophilia A, Congenital and Acquired): Advate, Adynovate, Afstyla, Eloctate, Helixate FS, Hemofil M, Koate-DVI, Kogenate FS, Kovaltry, Monoclate-P, Novoeight, NUWIQ, Recombinate, Xyntha, Obizur, Jivi and Esperoct | 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 J7204 |
|---|---|---|
| Extended Half-life Factor VIII Products: Altuviiio, Adynovate, Eloctate, Esperoct and Jivi | 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 J7204 |
|---|---|---|
| Clotting Factors, Coagulant Blood Products, & Other Hemostatics | Jan 1, 2026 | Covered |
| Policy | Effective | Status of J7204 |
|---|---|---|
| Clotting Factors, Coagulant Blood Products, & Other Hemostatics | Jan 1, 2026 | Covered |
| Policy | Effective | Status of J7204 |
|---|---|---|
| Clotting Factors, Coagulant Blood Products, & Other Hemostatics | Jan 1, 2026 | Covered |