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08.01.99c, Teplizumab-mzwv (Tzield)
Act
by Dec 7, 2026
Effective date
Dec 7, 2026
Identified
Sep 5, 2026
Summary
Independence Blue Cross expanded coverage for Teplizumab-mzwv (Tzield) to include pediatric patients aged 1 to <8 years with stage 2 type 1 diabetes, while maintaining non-coverage for patients aged 8-17 with stage 3 T1D (classified as experimental/investigational). Six ICD-10 diagnosis codes were removed from the policy. Billing teams must update systems to reflect the new pediatric age coverage expansion effective December 7, 2026.
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What to do
by Dec 7, 2026 · 6 steps
01Billing team must update authorization and claims submission logic in billing software to recognize Teplizumab-mzwv (Tzield, HCPCS J9381) as covered for pediatric patients aged 1 to <8 years with stage 2 type 1 diabetes (ICD-10 E10.A2) when all clinical criteria are met.
02Remove the six deleted ICD-10 codes (R73.01, R73.02, R73.03, R73.09, R76.0, Z83.3) from policy lookup tables.
03Continue to deny claims for patients aged 8-17 with stage 3 T1D as experimental/investigational.
04Providers should document patient age and disease stage at time of service.
05Update prior authorization templates to specify age requirements.
06Train billing and prior auth staff on the new age-based coverage split before the effective date.
If missed: Failure to implement these changes will result in claim denials for eligible pediatric patients in the newly covered age group.
Codes mentioned
J9381E10.A2R73.01R73.02R73.03R73.09R76.0Z83.3
Original notice
08.01.99c, Teplizumab-mzwv (Tzield)
medpolicy.ibx.com · Always check the source before changing claims.