Summary
Independence Blue Cross reissued its coverage policy for pozelimab-bbfg (Veopoz®) for CHAPLE disease (CD55-deficient protein-losing enteropathy) with no substantive changes. The policy confirms continued coverage for patients age 1+ meeting specific clinical and laboratory criteria, including confirmed biallelic CD55 mutations, documented symptoms, meningococcal vaccination, and specialist ordering. Billing teams should verify all prior authorization and documentation requirements are met before claim submission.
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What to do
Action · 5 steps
01No immediate action required.
02This is a reissue with no substantive changes to coverage criteria.
03However, verify that claims for HCPCS code J9376 (pozelimab-bbfg) include: (1) documentation of biallelic CD55 loss-of-function mutation confirmed by lab; (2) evidence of at least one CHAPLE symptom within 6 months (hypoalbuminemia ≤3.2 g/dL, facial/peripheral edema, diarrhea, abdominal pain, or thromboembolic event); (3) meningococcal vaccination (serogroups A, C, W, Y, and B) completed at least 2 weeks prior unless delay risks outweigh benefits; (4) provider credentials showing expertise in CHAPLE disease (Gastroenterology, Hematology, Immunology, rare genetic hematologic disease specialist); (5) confirmation patient is not receiving concurrent complement inhibitors.
04For continuation therapy, document that hypoalbuminemia and symptoms have improved or resolved from baseline.
05Update compliance templates and prior auth requirements if not already in place for this orphan drug.
Codes mentioned
J9376D84.1K90.49
Original notice
08.02.17, Pozelimab-bbfg (Veopoz®)
medpolicy.ibx.com · Always check the source before changing claims.
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