HCPCS J7192 is officially defined as "Factor viii (antihemophilic factor, recombinant) per i.u., not otherwise specified." HCPCS J7192 is referenced in 4 tracked payer policy changes from Florida Blue, Humana, and 2 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for HCPCS J7192 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Florida Blue Medicare updated its Part B Step Therapy program effective May 15, 2026, adding new non-preferred drugs and changing preferred status for medications in Asthma, Cancer, and Hemophilia categories. Providers must try preferred alternatives before prescribing non-preferred drugs or face coverage denials.
This is a historical policy document (issued 2026-01-01, discovered 2026-10-06) establishing Humana Medicaid Ohio's IVIG (immune globulin) prior authorization requirements across 25 product formulations and 24 clinical indications. The policy specifies preferred products, step-therapy rules, and approval criteria for conditions ranging from primary immunodeficiency to autoimmune diseases. Since this policy became effective on 2026-01-01 and is now 9 months past implementation, verify current applicability with Humana before applying these requirements.
Sentara Health Plans' authorization updates effective October 1, 2025 archived several policies, including Deep Brain Stimulation (Surgical 74), Electric Bone Growth Stimulation (DME 09), Near-infrared Spectroscopy (Medical 330) and Home Spirometry (DME 23), with the stimulation policies moved into the new Electrical Stimulation policy (Medical 349). On October 1, 2025, prior authorization became required (Y) for 44 listed procedure codes and for codes including 0420U, 0421U, 0435U, 0212U, 0213U, 81500, 81503, 81528, 88230 and 89420, with some codes directed to OncoHealth or Avalon, and 97161 and 97162 require authorization with benefit limits. Earlier updates effective July 1 and August 1, 2025 removed authorization for codes including 98975, 98976, 98977, 98978, 98980 and 98981, and required authorization for Medicaid codes 0253U, 0254U and 0255U.
Aetna's clotting factor policy applies to commercial medical plans, and the Medicare criteria are set out separately in the Medicare Part B Criteria. Precertification of clotting factors is required of all Aetna participating providers and members in applicable plan designs, and it is requested through Aetna's Special Case Precertification Unit at (855) 888-9046. Clotting factor products must be prescribed by or in consultation with a hematologist, and Aetna considers all other indications experimental, investigational, or unproven.
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