CommercialBilling CodesMedium impact
08.00.64i, Natalizumab (Tysabri®) and Related Biosimilars
Independence Blue Cross·Neurology, Gastroenterology, Pharmacy +1 more·Pharmacy
Effective date
Oct 1, 2025
We identified it
Oct 2, 2026
Summary
Independence Blue Cross reissued Policy 08.00.64i (Natalizumab/Tysabri and biosimilars) with updated ICD-10 diagnosis codes effective 10/01/2025. The policy replaced the broad 'G35 Multiple sclerosis' code with three specific codes (G35.A, G35.C1, G35.D) and added HCPCS code Q5134 for the biosimilar natalizumab-sztn (Tyruko). Medical necessity criteria remain substantially unchanged but now explicitly cover highly active relapsing MS, active secondary progressive MS, and Crohn's disease per updated FDA labeling.
Action Required
By October 1, 2025: (1) Billing team must update coding systems to recognize and use the three new ICD-10 diagnosis codes (G35.A, G35.C1, G35.D) for multiple sclerosis claims instead of the discontinued broad G35 code. (2) Update charge capture systems and encounter templates to support HCPCS code Q5134 for natalizumab-sztn (Tyruko) biosimilar claims alongside existing J2323 for brand natalizumab. (3) Verify that prior authorization and medical necessity validation rules in billing software reflect the two MS coverage pathways: (a) highly active/aggressive relapsing MS with specific disability/lesion documentation, OR (b) inadequate response/intolerance to alternate MS therapies. (4) Ensure anti-JCV antibody testing (CPT 86711) and anti-natalizumab antibody testing (CPT 83516 or 83518) are billed appropriately per policy requirements. (5) Pharmacy and clinical teams should confirm REMS program enrollment requirements for both TOUCH Prescribing Program (Tysabri) and Tyruko REMS program. Failure to use updated ICD-10 codes may result in claim denials or delays.