Pulmonology Coding Alert

Is patient eligible for Xolair? These questions will help you find outWhen determining medical necessity for Xolair injection claims, you'll have to answer questions about the patient's condition, age, and past asthma treatments to determine eligibility. If the patient does not meet even one of the eligibility requirements, the payer will not reimburse for Xolair administration.However, BlueCross BlueShield of Tennessee formulated a tool that will help you make the medical- necessity decision. To determine the eligibility status of patients who might receive Xolair, follow this Pharmaceutical Decision Support Tree:1. Has the individual been diagnosed with an allergic condition, other than allergy-related asthma?If yes, this does not meet medical-necessity and/or medical-appropriateness criteria.If no, go to question #2.2. Does the individual have a diagnosis of moderate to severe persistent allergic asthma?If yes, go to question #3.If no, this does not meet medical-necessity and/or medical-appropriateness criteria.3. Is the individual 12 years of age or older?If yes, go to question #4.If no, this does not meet medical-necessity and/or medical-appropriateness criteria.4. Did the individual test positive to at least one perennial aeroallergen by a skin test (for instance, prick/puncture test, intracutaneous test) or a blood test (such as RAST)?If yes, go to question #5.If no, this does not meet medical-necessity and/or medical-appropriateness criteria.5. Is the individual's IgE level greater than or equal to 30 and less than or equal to 700 IU/mL?If yes, go to question #6.If no, this does not meet medical-necessity and/or medical-appropriateness criteria.6. Is the individual currently using oral/inhaled corticosteroids at maximum doses?If yes, go to question #7.If no, this does not meet medical-necessity and/or medical-appropriateness criteria.7. Is the individual's asthma inadequately controlled despite the regular use of inhaled corticosteroids at maximum doses?If yes, go to question #8.If no, this does not meet medical-necessity and/or medical-appropriateness criteria.8. Is the individual being treated with a long-acting beta 2-agonist?If yes, this satisfies medical-necessity and medical- appropriateness criteriaIf no, this does not meet medical-necessity and/or medical-appropriateness criteria.