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08.00.41b, Teprotumumab-trbw (Tepezza®)
Act
by Jan 6, 2025
Effective date
Jan 6, 2025
Identified
Jun 19, 2026
Summary
Independence Blue Cross updated policy 08.00.41c for Teprotumumab-trbw (Tepezza) to expand coverage for thyroid eye disease (TED) to include both active AND inactive moderate-to-severe cases (previously active only), removed the Clinical Activity Score requirement, added criteria excluding patients with planned surgical ophthalmological intervention, and clarified that cosmetic-only use is not covered. Five additional ICD-10 diagnosis codes were added to the medically necessary list.
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What to do
by Jan 6, 2025 · 7 steps
01Billing team must update claim submission and prior authorization rules to reflect that Tepezza (J3241) now covers BOTH active and inactive moderate-to-severe TED, not just active disease.
02Remove Clinical Activity Score from any prior auth checklist or medical necessity templates.
03Add new screening question to prior auth forms: 'Does patient have planned surgical ophthalmological intervention for proptosis repair?' — if yes, deny coverage.
04Update EMR/billing system to include all nine ICD-10 codes (E05.10, E05.20, E05.30, E05.80, E05.90, H05.831, H05.832, H05.833, plus existing codes) as medically necessary for Tepezza claims.
05Providers and billing staff must clarify with patients upfront that Tepezza requests for cosmetic purposes only (appearance improvement without medical symptoms) will be denied as a benefit exclusion.
06Ensure prior auth reviewers understand the four mandatory exclusion criteria: patient must NOT have planned surgical ophthalmological intervention.
07Update reviewer training materials.
If missed: Failure to implement these changes will result in claim denials for eligible patients with inactive TED or incorrect denials for patients with planned surgery.
Codes mentioned
J3241E05.10E05.20E05.30E05.80E05.90H05.831H05.832H05.833
Original notice
08.00.41b, Teprotumumab-trbw (Tepezza®)
medpolicy.ibx.com · Always check the source before changing claims.
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