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MA08.177, Imetelstat (Rytelo™)
Act
by May 19, 2025
Effective date
May 19, 2025
Identified
Jun 19, 2026
Summary
Independence Blue Cross has published a new Medicare Advantage policy (MA08.177a, effective 05/19/2025) establishing coverage criteria for imetelstat (Rytelo®) in the treatment of adult patients with low- to intermediate-risk myelodysplastic syndromes (MDS) with transfusion-dependent symptomatic anemia. The policy replaces MA08.177 and specifies strict medical necessity requirements including bone marrow confirmation, transfusion history, risk stratification by IPSS-R score, cytogenetic profile, and prior failed treatment with ESA, luspatercept-aamt, G-CSF, or lenalidomide.
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What to do
by May 19, 2025 · 4 steps
01Billing team must implement prior authorization workflow for HCPCS code J0870 (imetelstat injection, 1 mg) for all Medicare Advantage members.
02Update billing system to require documentation of: (1) bone marrow biopsy/aspirate confirmation of MDS diagnosis, (2) transfusion history (4+ RBC units in 8 weeks with pre-transfusion hemoglobin ≤9.0 g/dL), (3) IPSS-R score confirming low or intermediate risk, (4) cytogenetic results confirming absence of del(5q), (5) ring sideroblast percentage and SF3B1 mutation status if applicable, and (6) evidence of prior treatment failure with ESA, luspatercept-aamt, G-CSF, or lenalidomide.
03Providers must attach supporting clinical documentation with all J0870 claims.
04Claims submitted without complete medical necessity documentation will be denied.
Codes mentioned
J0870
Original notice
MA08.177, Imetelstat (Rytelo™)
medpolicy.ibx.com · Always check the source before changing claims.