By Counterforce Health Team in Brensocatib (BRINSUPRI) —

Coding That Helps Get Brensocatib (BRINSUPRI) Approved by Blue Cross Blue Shield in New York: ICD-10, HCPCS, NDC Guide

Answer Box: Getting Brensocatib (BRINSUPRI) Covered in New York

Fastest path to approval: Submit prior authorization using ICD-10 code J47.1 (bronchiectasis with exacerbation), NDC from specialty pharmacy, and document failed macrolide therapy. Blue Cross Blue Shield typically covers under pharmacy benefit with specialty tier requirements. If denied, file internal appeal within plan timelines, then external review through New York DFS within 4 months. First step today: Contact your Blue Cross Blue Shield plan to verify current prior authorization form and specialty pharmacy network requirements.

Table of Contents

Coding Basics: Medical vs. Pharmacy Benefit Paths

Brensocatib (BRINSUPRI) is an oral medication, so most Blue Cross Blue Shield plans cover it under the pharmacy benefit, not medical benefit. This affects your coding approach:

Pharmacy Benefit Path (Most Common):

  • Use NDC number for claims
  • Specialty pharmacy dispensing required
  • High-tier coinsurance (25-40% typical)
  • Prior authorization through pharmacy benefit management

Medical Benefit Path (Rare):

  • Requires miscellaneous HCPCS code (J3490) plus NDC
  • "Buy and bill" model (uncommon for oral drugs)
  • Requires stronger justification for medical necessity
Tip: Call your specific Blue Cross Blue Shield plan to confirm benefit classification before submitting your first claim.

ICD-10 Mapping for Non-Cystic Fibrosis Bronchiectasis

Accurate diagnosis coding is critical for Brensocatib approval. Use these ICD-10 codes from the J47 category:

ICD-10 Code Description When to Use Documentation Keywords
J47.1 Bronchiectasis with (acute) exacerbation Active flare, increased symptoms "Exacerbation," "acute worsening," "increased cough/sputum"
J47.0 Bronchiectasis with acute lower respiratory infection Current infection present "Pneumonia," "acute infection," "positive cultures"
J47.9 Bronchiectasis, uncomplicated Stable chronic disease "Chronic," "stable," "maintenance therapy"

Documentation Words That Support Coding:

  • For J47.1: "Patient experiencing acute exacerbation with increased dyspnea and purulent sputum production"
  • For J47.0: "Acute lower respiratory infection superimposed on chronic bronchiectasis"
  • For J47.9: "Stable non-cystic fibrosis bronchiectasis on maintenance therapy"

Exclude These Codes:

  • Q33.4 (Congenital bronchiectasis)
  • A15.0 (Tuberculous bronchiectasis)

Product Coding: HCPCS, J-Codes, and NDC Overview

Current Coding Status (as of late 2025):

  • HCPCS J-Code: Not yet assigned (common for newly approved oral agents)
  • NDC Number: Contact Insmed or specialty pharmacy for current NDC
  • Billing Units: Always use mg (milligrams), never mg/kg

Dosing and Units:

  • Standard adult dose: 25 mg once daily
  • Pediatric (≥12 years): Same as adult dosing
  • Critical: Document as "25 mg tablet" not "25 mg/kg" to avoid billing errors

For Medical Benefit Claims (if applicable):

  • Use J3490 (miscellaneous drug) + NDC
  • Include detailed drug description in claim notes
  • Attach manufacturer information and FDA approval letter

Clean Request Anatomy: Sample PA Form

Here's a properly completed prior authorization request:

PATIENT INFORMATION:
Name: [Patient Name]
DOB: [Date]
Insurance ID: [Blue Cross Blue Shield Member ID]
Phone: [Contact Number]

PRESCRIBER INFORMATION:
Provider: [Pulmonologist Name]
NPI: [National Provider Identifier]
DEA: [If required]
Phone/Fax: [Contact Information]

MEDICATION DETAILS:
Drug Name: Brensocatib (BRINSUPRI)
Strength: 25 mg tablets
NDC: [Verify with specialty pharmacy]
Directions: One tablet by mouth daily
Quantity: 30 tablets per 30 days
Days Supply: 30

DIAGNOSIS INFORMATION:
Primary Diagnosis: Non-cystic fibrosis bronchiectasis
ICD-10 Code: J47.1 (with acute exacerbation)
Clinical History: Patient with confirmed bronchiectasis on CT imaging,
experiencing ≥2 exacerbations per year despite standard therapy

PRIOR THERAPIES:
1. Azithromycin 250 mg three times weekly × 6 months - inadequate response
2. Airway clearance therapy - ongoing
3. [Additional failed therapies]

MEDICAL NECESSITY:
FDA-approved indication for reducing exacerbations in non-cystic 
fibrosis bronchiectasis. Patient meets criteria with documented 
recurrent exacerbations and inadequate response to standard care.
Note: Attach clinical notes, imaging reports, and documentation of prior therapy failures.

Frequent Pitfalls: Unit Conversions and Code Mismatches

Common Billing Errors:

  1. Unit Conversion Mistakes:
    • ❌ Writing "25 mg/kg" instead of "25 mg"
    • ❌ Converting tablets to total mg incorrectly
    • ✅ Always use "mg" for adult dosing
  2. Mismatched Codes:
    • ❌ Using Q33.4 (congenital) for acquired bronchiectasis
    • ❌ Missing exacerbation status in ICD-10 selection
    • ✅ Match ICD-10 to current clinical status
  3. Missing Documentation:
    • ❌ No prior therapy documentation
    • ❌ Missing CT imaging confirmation
    • ✅ Include complete clinical history

Pre-Submission Review:

  • Verify NDC matches actual product strength
  • Confirm ICD-10 reflects current patient status
  • Double-check all unit calculations
  • Ensure specialty pharmacy is in-network

Verification with Blue Cross Blue Shield Resources

Before Submitting:

  1. Check Formulary Status: Visit your plan's drug formulary search tool
  2. Verify PA Requirements: Download current prior authorization form from member portal
  3. Confirm Specialty Pharmacy Network: Ensure dispensing pharmacy is contracted
  4. Review Coverage Policies: Look for specific Brensocatib coverage criteria

Blue Cross Blue Shield Plan-Specific Resources:

  • Member portal for formulary search
  • Provider portal for PA forms and submission
  • Pharmacy benefit manager contact information
  • Appeals and grievances department
Important: Each Blue Cross Blue Shield plan operates independently. Requirements may vary between states and plan types.

Quick Audit Checklist

Pre-Submission Review:

  • ICD-10 code matches current clinical status (J47.0, J47.1, or J47.9)
  • NDC number verified with specialty pharmacy
  • Dosing units in mg (not mg/kg)
  • Prior therapy failures documented with dates and outcomes
  • CT imaging confirming bronchiectasis diagnosis attached
  • Provider NPI and contact information complete
  • Patient insurance information current and accurate
  • Specialty pharmacy is Blue Cross Blue Shield contracted
  • Medical necessity narrative includes FDA indication
  • All required signatures and dates present

Appeals Process in New York

If your Brensocatib prior authorization is denied:

Step 1: Internal Appeal

  • Timeline: File within plan's specified timeframe (typically 60-180 days)
  • Submit through Blue Cross Blue Shield member or provider portal
  • Include additional clinical documentation and peer-reviewed literature

Step 2: External Appeal (New York DFS)

Expedited Appeals:

  • Available for urgent medical needs
  • Decision within 72 hours
  • Call (888) 990-3991 after faxing expedited request

Supporting Documentation for Appeals:

  • FDA approval letter for Brensocatib
  • ASPEN trial data showing efficacy
  • Peer-reviewed studies on bronchiectasis treatment
  • Patient-specific clinical notes and imaging

For assistance with appeals, contact Community Health Advocates at 888-614-5400 (free service for New York residents).

Cost Reduction Strategies

Manufacturer Support:

Foundation Grants:

  • Monitor Patient Access Network (PAN) and HealthWell Foundation for new bronchiectasis programs
  • Applications typically open when funding becomes available

State Programs:

  • New York State of Health marketplace plans
  • Medicaid expansion coverage for eligible patients
  • Essential Plan for those above Medicaid income limits

At Counterforce Health, we help patients and clinicians navigate complex prior authorization requirements by analyzing denial letters and crafting evidence-based appeals. Our platform identifies specific denial reasons and provides targeted rebuttals using payer-specific criteria and peer-reviewed evidence.

FAQ

How long does Blue Cross Blue Shield prior authorization take in New York? Standard decisions typically take 15 business days. Urgent requests are decided within 72 hours if medical urgency is documented.

What if Brensocatib is non-formulary on my plan? Request a formulary exception by documenting medical necessity and lack of suitable alternatives. Include FDA approval information and clinical trial data.

Can I request an expedited appeal if denied? Yes, if your health condition requires urgent treatment. New York allows expedited external appeals with decisions within 72 hours for urgent cases.

Does step therapy apply if I failed therapies outside New York? Document all prior therapies regardless of location. Blue Cross Blue Shield should accept out-of-state treatment history with proper documentation.

What happens if I miss the appeal deadline? You lose the right to external appeal through New York DFS. However, you may still have options through your plan's internal grievance process or state insurance regulators.

How do I find my Blue Cross Blue Shield plan's specific requirements? Log into your member portal or contact customer service. Each Blue Cross Blue Shield plan has independent policies and procedures.

What documentation proves medical necessity for Brensocatib? CT imaging confirming bronchiectasis, documentation of ≥2 exacerbations per year, failed standard therapies (macrolides, airway clearance), and FDA indication alignment.

Can my doctor do a peer-to-peer review? Yes, most Blue Cross Blue Shield plans offer peer-to-peer reviews where your prescribing physician can discuss the case directly with the plan's medical director.

Counterforce Health specializes in turning insurance denials into successful appeals through targeted, evidence-backed strategies. Our platform analyzes payer-specific policies and creates compelling medical necessity arguments that align with plan criteria and clinical guidelines. Learn more about our services.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by plan and individual circumstances. Always consult with your healthcare provider and insurance plan for specific guidance. For additional help with insurance appeals in New York, contact the New York Department of Financial Services at (800) 400-8882 or Community Health Advocates at (888) 614-5400.

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