CAM 20113

Human Antihemophilic Factor (AHF)

Category:Prescription Drug   Last Reviewed:June 2019
Department(s):Medical Affairs   Next Review:June 2020
Original Date:December 1995    

Description:
Human antihemophilic factor (AHF, Factor VIII) maintenance therapy is used as an alternative to "on-demand" therapy to reduce the incidence of bleeding episodes and resultant joint damage in patients who have severe hemophilia A (AHF activity <1 percent of normal). In on-demand therapy, human AHF concentrate is infused when trauma or joint pain is observed consistent with internal bleeding.


During maintenance therapy, also known as prophylactic therapy, human AHF concentrate is infused on a weekly schedule with the goal of maintaining AHF activity at a level sufficient to prevent bleeding (generally, AHF activity greater than 1 percent).

This policy specifically applies to: 

ADVATE, HELIXATE FS, KOGENATE FS, RECOMBINATE, XYNTHA, NOVOEIGHT, ADYNOVATE, ELOCTATE, ALPHANATE, HUMATE-P, KOATE

(antihemophilic factor VIII [recombinant])

 

HEMOFIL M, MONOCLATE-P

(antihemophilic factor VIII [human] monoclonal antibody purified)

 

JIVI

(antihemophilic factor [recombinant] PEGylated-aucl)

 

Policy:
Coverage of these medications is provided when the FDA-approved indications below are met and there has been a trial and failure of preferred therapy.

The use of human antihemophilic factor (AHF) maintenance therapy for severe hemophilia A (i.e., AHF activity <1 percent of normal) is MEDICALLY NECESSARY for the following:

  • Maintain the trough AHF activity at greater than 1 percent
  • For the treatment of acute and significant bleeding

Benefit Application:
BlueCard®/National Account Issues
Human antihemophilic factor is a blood derivative applicable for processing under the Blood benefit if defined to include blood derivatives; otherwise, it may be processed under Prescription Drugs when utilized and defined as drugs.

References:

  1. American Red Cross. Practice Guidelines for Blood Transfusion: A Compilation from Recent Peer Reviewed Literature. May 2002.

Coding Section

Codes Number Description
CPT 96365

Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour

  96366

Each additional hour, (List separately in addition to code for primary procedure)

ICD-9 Procedure  99.29

Injection or infusion of other therapeutic or prophylactic substance

ICD-9 Diagnosis 286.0

Congenital Factor VIII disorder

HCPCS C9132 

Prothrombin complex concentrate (human), Kcentra, per i.u. of Factor IX activity 

  C9136

Injection, factor Viii, fc fusion protein, (recombinant), per iu 

  C9141 

Injection, factor viii, (antihemophilic factor, recombinant), pegylated-aucl (jivi), 1 IU

  J2597 

Injection, desmopressin, acetate, per 1 mcg 

  J7178 

Injection, human fibrinogen concentrate, 1mg 

  J7180 

Injection, factor XIII (antihemophilic factor, human), 1 IU 

  J7181 

Injection, factor XIII A-subunit, (recombinant), per IU  

  J7182 

Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU

  J7183 

Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo 

  J7185 

Injection, factor VIII (antihemophilic factor, recombinant) (XYNTHA), per IU 

  J7186 

Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per factor VIII i.u. 

  J7187 

Injection, von Willebrand factor complex (Humate-P), per IU VWF:RCO 

  J7189 

Factor VIIa (antihemophilic factor, recombinant), per 1 mcg 

  J7190

Factor VIII (antihemophilic factor, human), per IU

  J7191

Factor VIII (antihemophilic factor (porcine), per IU

  J7192

Factor VIII (antihemophilic factor, recombinant), per IU, not otherwise specified

 

J7193 

Factor IX (antihemophilic factor, purified, nonrecombinant), per IU 

  J7194 

Factor IX complex, per IU  

  J7195 

INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER IU, NOT OTHERWISE SPECIFIED  (REVISED CODE)

  J7198 

Antiinhibitor, per IU 

  J7199 

Hemophilia clotting factor, not otherwise classified 

  J7200 

Injection, factor IX, (Antihemophilic Factor, Recombinant), Rixubis, Per IU 

  J7201 

Injection, factor IX, FC Fusion Protein (Recombinant), Per IU 

  J7205 

Injection, factor viii fc fusion protein (recombinant), per iu 

  J7207 

Injection, factor viii, (antihemophilic factor, recombinant), pegylated, 1 i.u. 

  J7208 (effective 07/01/2019)

Injection, factor viii, (antihemophilic factor, recombinant), pegylated-aucl, (jivi), 1 i.u 

  J7209 

Injection, factor viii, (antihemophilic factor, recombinant), (nuwiq), 1 i.u. 

  J7210 (effective 1/1/2018)

Injection, factor viii, (antihemophilic factor, recombinant), (afstyla), 1 i.u. 

  J7211 (effective 1/1/2018) 

Injection, factor viii, (antihemophilic factor, recombinant), (kovaltry), 1 i.u 

  S9345 

home infusion therapy, anti-hemophilic agent infusion therapy (e.g., Factor VIII); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem 

ICD-10-CM (effective 10/01/15)  D66  Hereditary factor VIII deficiency
ICD-10-PCS (effective 10/01/15)  3E013GC Introduction of Other Therapeutic Substance into Subcutaneous Tissue, Percutaneous Approach
Type of Service Medicine  
Place of Service Inpatient; Outpatient; Home  

 

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations other plan medical policies and accredited national guidelines.

"Current Procedural Terminology© American Medical Association.  All Rights Reserved" 

History From 2013 Forward     

07/19/2019 

Added code J7208. 

06/01/2019 

Annual review including specific product names and updating coding. No other changes made. 

05/30/2018 

Interim review, changing review month. Adding the following statement to the medical necessity policy verbiage: Coverage of these medications is provided when the FDA-approved indications below are met and there has been a trial and failure of preferred therapy. 

02/28/2018 

Annual review. No change to policy. 

11/27/2017

Updating with 2018 coding. No other changes.

02/08/2017 

Annual Review. No change to policy 

02/02/2016 

Annual Review. No change to policy. 

11/05/2015 

Change category from Medicine to Prescription Drug 

09/30/2015 

Added ICD-10 HCPCS codes 

09/21/2015 

Added ICD-10 codes. 

03/05/2015 

Disclaimer removed. 

02/10/2015

Annual review, adding coding. Policy to remain active, but will not undergo scheduled review after 2015.

02/3/2014

Annual review. No change to policy.


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