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CommercialCoverageMedium impact

State and School Employees' Health Insurance Plan - Daptomycin

Blue Cross & Blue Shield of Mississippi·MS · Infectious Disease, Dermatology, General Surgery +2 more·Medical Policy
Effective date
Not stated
We identified it
Jun 20, 2026
Days to comply
—

Summary

New policy establishes medical necessity criteria for daptomycin (Cubicin) injections for State and School Employees' Health Insurance Plan members. Coverage requires specific infection types, vancomycin failure or resistance documentation, and infectious disease specialist involvement with defined approval periods.

Action Required

Action needed
Immediately: Billing team must verify all daptomycin injection claims (J0872-J0878) include required documentation: culture/sensitivity reports showing vancomycin failure or resistance, infectious disease specialist consultation, and appropriate diagnosis codes for complicated skin infections or S. aureus bacteremia. Claims without complete documentation will be denied.

Affected Billing Codes

J0872
J0873
J0874
J0877
J0878
A41.01
A41.02
A49.01
A49.02
B95.0
B95.1
B95.2
B95.4
B95.61
B95.62
I33.0
I33.9
L01.00
L01.01
L01.02
L01.03
L01.09
L01.1
L02.01
L02.02
L02.03
L02.11
L02.12
L02.13
L02.211
L02.212
L02.213
L02.214
L02.215
L02.216
L02.217
L02.219
L02.221
L02.222
L02.223
L02.224
L02.225
L02.226
L02.227
L02.229
L02.231
L02.232
L02.233
L02.234
L02.235
L02.236
L02.239
L02.31
L02.32
L02.33
L02.411
L02.412
L02.413
L02.414
L02.415
L02.416
L02.419
L02.421
L02.422
L02.423
L02.424
L02.425
L02.426
L02.429
L02.431
L02.432
L02.433
L02.434
L02.435

Related policy hubs

Blue Cross & Blue Shield of Mississippi policiesMS policy changesInfectious DiseaseDermatologyGeneral SurgeryEmergency MedicineCritical CareCode J0872Code J0873Code J0874Code J0877Code J0878Code A41.01Code A41.02Code A49.01Code A49.02Code B95.0Code B95.1Code B95.2Code B95.4Code B95.61Code B95.62Code I33.0Code I33.9Code L01.00Code L01.01Code L01.02Code L01.03Code L01.09Code L01.1Code L02.01Code L02.02Code L02.03Code L02.11Code L02.12Code L02.13Code L02.211Code L02.212Code L02.213Code L02.214Code L02.215Code L02.216Code L02.217Code L02.219Code L02.221Code L02.222Code L02.223Code L02.224Code L02.225Code L02.226Code L02.227Code L02.229Code L02.231Code L02.232Code L02.233Code L02.234Code L02.235Code L02.236Code L02.239Code L02.31Code L02.32Code L02.33Code L02.411Code L02.412Code L02.413Code L02.414Code L02.415Code L02.416Code L02.419Code L02.421Code L02.422Code L02.423Code L02.424Code L02.425Code L02.426Code L02.429Code L02.431Code L02.432Code L02.433Code L02.434Code L02.435