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Check With Payer for Hizentra Coverage

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  • In CMS
  • October 29, 2010
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Effective for service dates on or after Dec. 15, HCPCS Level II code J3490 Unclassified drugs will be non-covered as a self-administered drug when used to bill Medicare Part B for Hizentra™ (Immune Globulin Subcutaneous (Human) (IGSC)). This is in accordance with the recently updated Self-Administered Drug Exclusions List, TrailBlazer Health Enterprises announced Oct. 22 in a notice posted on its website.

Hizentra, supplied in single-use vials of 5 mL, 10 mL, or 20 mL, is an IGSC 20 percent liquid indicated for the treatment of primary immunodeficiency (PI)—generally reported with an ICD-9-CM code under category 279 Disorders involving the immune mechanism. It is actively marketed as a weekly subcutaneous infusion.

Other Payer Policies May Vary

Cigna Government Services posted a notice on its website June 3 stating that Hizentra meets the requirements necessary for inclusion in the durable medical equipment Medicare administrative contractor (DME MAC) External Infusion Pump local coverage determination (LCD) as a covered IGSC when used for the treatment of primary immune deficiency disease. Coverage is effective for claims with service dates on or after March 4.
Claims submitted to the jurisdiction C DME MAC for Hizentra administered with a DME infusion pump should be submitted using HCPCS Level II code J7799 NOC drugs, other than inhalation drugs, administered through DME. An E0779 Ambulatory infusion pump, mechanical, reusable, for infusion 8 hours or greater is covered for the administration of subcutaneous immune globulin, Cigna adds.

Further Changes Are Forthcoming

At a HCPCS Level II public meeting held May 4 at the Centers for Medicare & Medicaid Services (CMS) Baltimore, Md. headquarters, a preliminary decision was made to establish Jxxxx Injection, immune globulin (Hizentra), 100 mg. In fact, J1559 for Hizentra was just released in the 2011 HCPCS update.
The moral of this story is to check your payer’s current policy for Hizentra, and check it often.

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