Burosumab-twza (Crysvita) (CPB 0932, reviewed 2026-01-13)

Effective immediately: (1) Billing team must implement precertification requirement for ALL burosumab-twza (Crysvita) claims using HCPCS code J0584. Direct all providers to obtain precertification by calling (866) 752-7021 or faxing (888) 267-3277 before dispensing. (2) Update billing system to reject claims with J0584 lacking precertification documentation. (3) Add workflow rule requiring Statement of Medical Necessity (SMN) for all J0584 requests submitted through Specialty Pharmacy Precertification process. (4) Providers must verify prescriber specialty (endocrinologist, nephrologist, or metabolic bone disorder specialist) before claim acceptance; flag non-compliant prescribers. (5) Billing team must validate claims meet XLH or TIO diagnostic criteria per policy before submission—deny claims for experimental indications (cutaneous-skeletal hypophosphatemia, fibrous dysplasia, tyrosinemia type 1). (6) For continuation of therapy requests, document evidence of benefit (phosphate normalization, pain/fracture improvement, skeletal deformity reduction) in medical records before reauthorization. Failure to obtain precertification will result in claim denial. Site of care utilization management policy also applies—verify administration setting per specialty drug infusion requirements before billing.