By Counterforce Health Team in Darzalex / Darzalex Faspro (daratumumab) —

Coding That Helps Get Darzalex/Darzalex Faspro (Daratumumab) Approved by Humana in Michigan: ICD-10, J-Codes & Appeal Guide

Answer Box: Getting Darzalex/Darzalex Faspro Covered by Humana in Michigan

Humana requires prior authorization for Darzalex (daratumumab) in 2024. The fastest path to approval: ensure proper ICD-10 coding (C90.00-C90.02 for multiple myeloma, E85.4/E85.9 for AL amyloidosis), use correct HCPCS code J9144 for Faspro billing, and submit complete clinical documentation through Humana's provider portal. If denied, Michigan residents have 127 days to file an external review with DIFS, which decides within 60 days (or 72 hours for expedited cases).

First step today: Verify your diagnosis codes match your treatment plan and gather prior therapy documentation before submitting your PA request.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit Paths
  2. ICD-10 Mapping for Multiple Myeloma and AL Amyloidosis
  3. Product Coding: HCPCS J-Codes and NDC Requirements
  4. Clean Request Anatomy: Building Your PA Submission
  5. Frequent Pitfalls and How to Avoid Them
  6. Verification Steps with Humana Resources
  7. Appeals Process in Michigan
  8. Quick Audit Checklist
  9. FAQ

Coding Basics: Medical vs. Pharmacy Benefit Paths

Understanding whether Darzalex falls under Medicare Part B (medical benefit) or Part D (pharmacy benefit) is crucial for proper coding and approval through Humana.

Part B Coverage (Most Common)

Part D Coverage (Rare)

  • Only applies if daratumumab is self-administered at home (uncommon)
  • Must be on Humana's formulary
  • Subject to formulary tiers and quantity limits
Note: Humana follows Medicare rules where site of administration and FDA labeling determine benefit classification.

ICD-10 Mapping for Multiple Myeloma and AL Amyloidosis

Precise ICD-10 coding is essential for Humana approval. Use the most specific codes available based on your clinical documentation.

Primary ICD-10 Codes

Condition ICD-10 Code Description Documentation Requirements
Multiple Myeloma C90.00 Not having achieved remission Initial diagnosis, active disease
Multiple Myeloma C90.01 In remission Response to prior therapy documented
Multiple Myeloma C90.02 In relapse Previous remission, now progressing
AL Amyloidosis E85.4 Organ-limited amyloidosis Biopsy confirmation, organ involvement
AL Amyloidosis E85.8 Other amyloidosis Light chain type confirmed
AL Amyloidosis E85.9 Amyloidosis, unspecified When specific type unclear

Documentation Words That Support Coding

For Multiple Myeloma:

  • "Plasma cell dyscrasia"
  • "Monoclonal protein"
  • "Bone marrow infiltration"
  • "Lytic lesions"
  • "Hypercalcemia"

For AL Amyloidosis:

  • "Congo red positive"
  • "Apple-green birefringence"
  • "Light chain deposition"
  • "Cardiac/renal/hepatic involvement"
Tip: Janssen provides ICD-10 support resources for healthcare providers to ensure proper coding alignment.

Product Coding: HCPCS J-Codes and NDC Requirements

Darzalex Faspro (Subcutaneous)

HCPCS Code: J9144 - "Injection, daratumumab, 10 mg and hyaluronidase-fihj"

Key Billing Details:

  • NDC: 57894-0503-01 (1,800 mg/15 mL vial)
  • Billing Unit: 1 unit = 10 mg daratumumab
  • Standard Dose: 1,800 mg = 180 billing units
  • Administration: Subcutaneous injection

Units Calculation Example

For a typical 1,800 mg dose:

  • Total dose: 1,800 mg
  • Billing calculation: 1,800 mg ÷ 10 mg per unit = 180 units
  • Bill: J9144 x 180 units

Required Modifiers

CMS requires specific modifiers for single-dose vials:

  • JW Modifier: Use when drug is discarded/wasted
  • JZ Modifier: Use when no wastage occurs (full utilization)

Clean Request Anatomy: Building Your PA Submission

Essential Components

1. Patient Information

  • Humana member ID
  • Complete demographics
  • Primary and secondary insurance details

2. Diagnosis Documentation

  • Specific ICD-10 codes (C90.00-02, E85.4/E85.8/E85.9)
  • Date of diagnosis
  • Staging information if applicable
  • Biopsy/pathology reports

3. Clinical Justification

  • Prior therapy history and outcomes
  • Treatment failures or intolerances
  • Current disease status
  • Treatment goals and monitoring plan

4. Prescriber Information

  • NPI number
  • Specialty (hematology/oncology)
  • Contact information for peer-to-peer review

Sample PA Request Structure

Patient: [Name], DOB [Date], Humana ID: [Number]
Diagnosis: Multiple myeloma, not in remission (ICD-10: C90.00)
Requested: Darzalex Faspro 1,800 mg subcutaneous monthly
Prior therapies: Lenalidomide + dexamethasone (failed due to progression)
Clinical rationale: NCCN guidelines support daratumumab for relapsed/refractory MM
Supporting documentation: Attached pathology, recent labs, imaging

Frequent Pitfalls and How to Avoid Them

Common Coding Errors

Unit Conversion Mistakes

  • Wrong: Billing 1,800 units for 1,800 mg dose
  • Correct: Billing 180 units (1,800 mg ÷ 10 mg per unit)

Missing Modifiers

  • Always include JW or JZ modifier for single-dose vials
  • Document actual waste vs. full utilization

ICD-10 Specificity

  • Avoid: Using unspecified codes (C90.0) when more detail available
  • Prefer: Specific remission status (C90.00, C90.01, C90.02)

Documentation Gaps

Insufficient Prior Therapy History

  • Document specific agents tried, duration, and reason for discontinuation
  • Include dates and response assessment

Missing Clinical Rationale

  • Connect diagnosis to treatment choice
  • Reference appropriate guidelines (NCCN, ASH, IMWG)

Verification Steps with Humana Resources

Before Submitting

  1. Check Current Formulary Status
  2. Confirm Submission Method
    • Online: Humana provider portal
    • Phone: 1-877-486-2621 (Mon-Fri, 8 a.m.-8 p.m. EST)
    • Fax: (verify current number with Humana)
  3. Review Coverage Criteria

Cross-Reference Checklist

  • ICD-10 codes match clinical documentation
  • HCPCS J-code aligns with product requested
  • NDC number is current and accurate
  • Units calculated correctly
  • Required modifiers included
  • All supporting documents attached

Appeals Process in Michigan

If Humana denies your Darzalex request, Michigan residents have robust appeal rights through both internal and external review processes.

Internal Appeals (First Step)

Timeline: Must file within 60 days of denial Process: Submit through Humana member portal or by phone Decision Time:

  • Standard: 30 days for medical services
  • Expedited: 72 hours if health would be jeopardized

External Review Through Michigan DIFS

When to Use: After receiving final denial from Humana's internal appeal

Timeline to File: 127 days from final denial

Decision Timeframes:

  • Standard: 60 days maximum
  • Expedited: 72 hours (requires physician certification of urgency)

How to File:

Required Documentation for Appeals

  • Original denial letter from Humana
  • All internal appeal correspondence
  • Complete medical records supporting necessity
  • Physician letter (for expedited review)
  • Treatment timeline and prior therapy failures
Important: DIFS external review decisions are binding on insurers, providing a final resolution pathway.

Quick Audit Checklist

Pre-Submission Review

Coding Verification

  • ICD-10 codes are most specific available (C90.00-02, E85.4/8/9)
  • HCPCS code J9144 used for Darzalex Faspro
  • NDC 57894-0503-01 listed correctly
  • Units calculated as dose in mg ÷ 10
  • JW or JZ modifier included

Clinical Documentation

  • Diagnosis confirmed with pathology/biopsy
  • Prior therapy history documented with outcomes
  • Current disease status clearly stated
  • Treatment rationale references guidelines
  • Prescriber NPI and specialty included

Administrative Details

  • Humana member ID verified
  • Site of care appropriate for Part B coverage
  • All required forms completed
  • Supporting documents attached
  • Submission method confirmed

At Counterforce Health, we understand that navigating insurance approvals for complex treatments like Darzalex can be overwhelming. Our platform helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to create compelling rebuttals that align with each payer's specific requirements.

FAQ

How long does Humana prior authorization take for Darzalex in Michigan? Standard PA decisions take up to 14 days (reducing to 7 days in 2026). Expedited requests for urgent cases are processed within 72 hours.

What if Darzalex Faspro is non-formulary on my Humana plan? You can request a formulary exception through Humana's standard PA process. Provide clinical documentation showing medical necessity and why formulary alternatives aren't appropriate.

Can I request an expedited appeal if my treatment is urgent? Yes. Both Humana's internal appeals and Michigan DIFS external reviews offer expedited processes (72 hours) when a physician certifies that delays would jeopardize your health.

Does step therapy apply to Darzalex in Michigan Humana plans? Humana may require step therapy for certain Part B drugs. Check your specific plan's requirements and request exceptions based on prior therapy failures or contraindications.

What happens if I disagree with Michigan DIFS external review decision? You can seek judicial review in Michigan circuit court within 60 days of the DIFS decision, though external review decisions are binding on insurers.

How do I get help with coding for complex cases? Contact your practice's billing department or consider using specialized services like Counterforce Health that provide targeted support for insurance appeals and prior authorization submissions.

From our advocates: "We've seen cases where proper ICD-10 coding made the difference between approval and denial. One patient's initial request was denied because they used C90.0 (unspecified multiple myeloma) instead of C90.02 (in relapse). After resubmitting with the correct code and documentation of disease progression, Humana approved the Darzalex Faspro within a week. The key is matching your clinical documentation to the most specific code available."

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies change frequently. Always verify current requirements directly with Humana and consult with your healthcare provider about treatment decisions. For personalized assistance with insurance appeals, consider consulting with healthcare advocates or services like Counterforce Health that specialize in prior authorization and appeals processes.

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