CommercialCoverageHigh impact
08.00.92ak, Coagulation Factors
Independence Blue Cross·PA · Hematology, Pharmacy, Pediatrics·Medical Policy
Effective date
Jan 1, 2026
We identified it
Jun 19, 2026
Summary
Independence Blue Cross updated policy 08.00.92ak effective 01/01/2026 to add coverage for two new coagulation factor products: Concizumab-mtci (Alhemo) and Fitusiran (Qfitlia) for hemophilia A and B treatment with or without inhibitors. One new HCPCS code (J7174) was added for fitusiran; Concizumab-mtci uses existing unclassified drug codes (C9399, J3590). All ICD-10 diagnosis codes were removed from the policy—providers must report the most appropriate diagnosis code supporting medical necessity.
Action Required
By 12/31/2025: (1) Billing team must update billing system to recognize J7174 (fitusiran/Qfitlia) and ensure C9399 and J3590 are properly configured for Concizumab-mtci (Alhemo) claims. (2) Remove all hardcoded ICD-10 diagnosis codes from templates and ensure providers manually select and document the most appropriate hemophilia diagnosis code (e.g., D66, D67, D68.0-D68.1) for each claim in support of medical necessity. (3) Update encounter forms and claim submission workflows to require explicit diagnosis code selection before billing. (4) For Pennsylvania members: Verify whether these coagulation factors are covered under Medical Benefit (when administered by provider in facility setting) or Pharmacy Benefit (self-administered); coordinate with Pharmacy Benefit Administrator for specialty pharmacy distribution options. (5) Train billing staff on the new products and coverage criteria for hemophilia A, B, and inhibitor scenarios. Failure to report appropriate diagnosis codes or misconfigured HCPCS codes will result in claim denials.