Summary
Independence Blue Cross expanded coverage of teplizumab-mzwv (Tzield) effective 12/07/2026 to include pediatric individuals ages 1 to <8 years with stage 2 type 1 diabetes. Simultaneously, the policy clarified that use in ages 8-17 with stage 3 T1D remains experimental/investigational and not covered. Six ICD-10 diagnosis codes (R73.01, R73.02, R73.03, R73.09, R76.0, Z83.3) were removed from the policy.
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What to do
Action · 5 steps
01By 12/07/2026: Billing team must update authorization and claims submission protocols to reflect the expanded coverage for teplizumab-mzwv (Tzield) in pediatric individuals ages 1 to <8 years with stage 2 T1D.
02Verify that the practice's billing system and prior authorization workflows correctly identify eligible pediatric patients (ages 1 to <8, stage 2 T1D) as covered and routes denials appropriately for non-covered age groups (ages 8-17 with stage 3 T1D, classified as experimental/investigational).
03Remove the six delisted ICD-10 codes (R73.01, R73.02, R73.03, R73.09, R76.0, Z83.3) from claim submissions for this medication.
04Coordinate with endocrinology providers to ensure prescribers understand the age-based coverage boundary and updated clinical criteria.
05Confirm that claims for the HCPCS code J9381 under ICD-10 code E10.A2 and stage 2 designation will process without denial for the newly covered pediatric population.
Codes mentioned
J9381E10.A2
Original notice
08.01.99c, Teplizumab-mzwv (Tzield)
medpolicy.ibx.com · Always check the source before changing claims.