By Counterforce Health Team in Eloctate (coagulation factor VIII, rFVIIIFc; efmoroctocog alfa) —

Coding That Helps Get Eloctate Covered by UnitedHealthcare in Washington (ICD-10, HCPCS/J-Code, NDC Guide)

Answer Box: Getting Eloctate Coded Correctly for UnitedHealthcare Coverage in Washington

Quick Path to Approval: Use ICD-10 code D66 for hemophilia A, HCPCS J7205 for billing, and match the exact NDC to your vial strength. UnitedHealthcare requires prior authorization with hematologist prescription and stays within 40,250 units per 30-day supply. If denied, you have 60 days for internal appeal, then 21 days for Washington's external IRO review. Start by gathering your factor VIII levels, bleeding logs, and specialist notes—then submit through UnitedHealthcare's provider portal.

Table of Contents

Coding Basics: Medical vs. Pharmacy Benefit Paths

Understanding whether Eloctate (efmoroctocog alfa) falls under your medical or pharmacy benefit determines which codes you'll use and how claims get processed.

Medical Benefit Path:

  • Used when Eloctate is administered in clinical settings (hospitals, outpatient clinics, infusion centers)
  • Requires HCPCS code J7205 plus the specific NDC
  • Billed per international unit (IU) administered
  • Often subject to buy-and-bill procedures

Pharmacy Benefit Path:

  • Used for home infusion and self-administration
  • Billed using NDC codes only (no J-codes)
  • Processed through specialty pharmacies
  • Subject to pharmacy benefit copays and deductibles
Note: Most UnitedHealthcare plans cover Eloctate under the pharmacy benefit for routine prophylaxis, switching to medical benefit only for inpatient care or emergency situations.

ICD-10 Mapping for Hemophilia A

The foundation of any successful Eloctate claim starts with the correct diagnosis code.

Primary Code: D66

  • D66 - Hereditary factor VIII deficiency (hemophilia A)
  • This is your main code for all Eloctate claims
  • Must be supported by documented factor VIII activity levels

Supporting Documentation Words That Strengthen Your Coding:

  • "Severe hemophilia A" (factor VIII <1%)
  • "Moderate hemophilia A" (factor VIII 1-5%)
  • "Spontaneous bleeding episodes"
  • "Joint hemorrhage" or "hemarthrosis"
  • "Prophylactic therapy indicated"
  • "Previous factor concentrate therapy"

Additional Codes When Applicable:

  • Z79.899 - Other long-term drug therapy (for ongoing prophylaxis)
  • Z29.89 - Other specified prophylactic measure
  • M25.0 series - Joint hemarthrosis (if documenting specific joint bleeds)
Tip: Always include recent factor VIII activity lab results (≤6 months old) to support your D66 diagnosis. UnitedHealthcare reviewers look for levels <5% for routine prophylaxis approval.

Product Coding: HCPCS, J-Codes, and NDCs

Getting the product codes right prevents most billing rejections and speeds up approvals.

HCPCS/J-Code: J7205

J7205 covers "Injection, factor VIII (antihemophilic factor, recombinant), per IU"

  • Used for all recombinant factor VIII products including Eloctate
  • Billed per international unit administered
  • Must include corresponding NDC on the claim

NDC Requirements by Vial Strength

Vial Strength NDC Typical Use
250 IU 71104-0801-01 Pediatric/breakthrough
500 IU 71104-0802-01 Pediatric prophylaxis
750 IU 71104-0803-01 Low-weight adults
1000 IU 71104-0804-01 Standard adult dose
1500 IU 71104-0805-01 Adult prophylaxis
2000 IU 71104-0806-01 Higher-weight patients
3000 IU 71104-0807-01 On-demand therapy
4000 IU 71104-0808-01 Surgical prophylaxis
5000 IU 71104-0809-01 Major surgery
6000 IU 71104-0810-01 Highest strength

Units Calculation Formula

Standard Eloctate Dosing: 1 IU/kg raises factor VIII by 2%

Required Dose (IU) = Body weight (kg) × Desired factor VIII rise (%) × 0.5

Example: 70 kg patient needing 50% factor VIII level

  • Dose = 70 kg × 50% × 0.5 = 1,750 IU
  • Use 1500 IU + 250 IU vials or single 2000 IU vial
Critical: UnitedHealthcare limits coverage to 40,250 units per 30-day supply. Exceeding this triggers automatic denials.

Clean Request Anatomy: Building Your PA

Here's what a complete prior authorization request looks like:

Patient Information Section

  • Name: [Patient full name]
  • DOB: [MM/DD/YYYY]
  • Member ID: [UnitedHealthcare ID]
  • Diagnosis: D66 - Hereditary factor VIII deficiency

Clinical Documentation

  • Factor VIII Activity Level: <1% (severe hemophilia A)
  • Weight: 70 kg
  • Prescribed Regimen: 50 IU/kg every 4 days (prophylaxis)
  • Calculated Dose: 3,500 IU per infusion
  • Monthly Units: 26,250 IU (within 40,250 limit)

Prescriber Information

  • Hematologist Name: Dr. [Name], MD
  • NPI: [10-digit number]
  • Specialty: Hematology/Oncology
  • Phone: [Direct line for peer-to-peer]

Supporting Documents

  • Recent bleeding log (past 6 months)
  • Factor VIII activity lab results
  • Previous treatment history
  • Pharmacy dispensing records (if switching products)

When patients and clinicians work with Counterforce Health, our platform automatically pulls together these elements, matches them to UnitedHealthcare's specific requirements, and drafts targeted appeals that address the exact denial reasons in your case.

Frequent Pitfalls and How to Avoid Them

Unit Conversion Errors

Problem: Mixing up IU calculations or using wrong conversion factors Fix: Always use the 0.5 multiplier for Eloctate; double-check math before submitting

Mismatched NDCs

Problem: Billing NDC doesn't match actual vial dispensed Fix: Verify NDC on physical vial matches claim; use exact strength dispensed

Missing Start Dates

Problem: PA requests without clear therapy start date Fix: Include specific "therapy initiation date" and "next infusion due" dates

Exceeding Unit Limits

Problem: Monthly claims over 40,250 units get auto-denied Fix: Calculate total monthly units before submitting; adjust dosing schedule if needed

Non-Specialist Prescribing

Problem: Primary care or non-hematology prescriptions get rejected Fix: Ensure hematologist writes prescription and provides clinical oversight

Verification with UnitedHealthcare Resources

Before submitting any Eloctate request, cross-check these UnitedHealthcare resources:

Provider Portal Verification

  1. Log into UnitedHealthcare Provider Portal
  2. Navigate to "Prior Authorization" section
  3. Search "Clotting Factors" or "J7205" for current requirements
  4. Download most recent PA form (forms update quarterly)

Coverage Policy Check

  • Review current "Clotting Factors and Coagulant Blood Products" policy
  • Confirm Eloctate's formulary status (may require step therapy)
  • Check for any new quantity limits or site-of-care restrictions

Member Benefit Verification

  • Use eligibility tool to confirm pharmacy vs. medical benefit
  • Check member's specific copay/coinsurance for specialty drugs
  • Verify prior authorization requirements haven't changed
Important: UnitedHealthcare updates policies frequently. Always use the most current forms and requirements found on their official provider portal.

Quick Audit Checklist

Before submitting your Eloctate request, verify:

☐ Diagnosis Coding

  • D66 included as primary diagnosis
  • Supporting lab values documented
  • Severity level specified (mild/moderate/severe)

☐ Product Coding

  • J7205 for medical benefit claims
  • Correct NDC matching vial strength
  • Units calculated accurately

☐ Clinical Documentation

  • Hematologist prescription and oversight
  • Recent factor VIII levels (≤6 months)
  • Bleeding history and frequency
  • Treatment goals clearly stated

☐ Administrative Requirements

  • Current PA form used
  • All required fields completed
  • Supporting documents attached
  • Submission within required timeframes

☐ Unit Limits

  • Monthly total ≤40,250 units
  • Dosing schedule documented
  • Rationale for any high-dose requests

Washington Appeals Process

If your properly coded Eloctate request gets denied, Washington provides strong consumer protections.

Internal Appeal (UnitedHealthcare)

  • Deadline: 60 days from denial notice
  • Expedited: 72 hours for urgent cases
  • Continuation: Request within 10 days to maintain coverage during appeal

External Independent Review (IRO)

  • When: After UnitedHealthcare upholds denial
  • Deadline: 21 days from final internal decision
  • Process: Independent medical experts review your case
  • Timeline: Decision within 30 days (72 hours if expedited)

Washington State Resources

  • Office of Insurance Commissioner: 1-800-562-6900
  • Consumer Advocacy: Free assistance with appeals
  • External Review Request: Available online or by phone

The external review process in Washington is particularly strong for specialty drugs like Eloctate. Independent reviewers often have hematology expertise and can override insurance company decisions based on medical necessity.

For complex cases involving multiple denials or unusual circumstances, Counterforce Health specializes in turning denials into successful appeals by identifying the specific policy language and clinical evidence needed to overturn UnitedHealthcare's decisions.

FAQ

How long does UnitedHealthcare prior authorization take for Eloctate? Standard review takes 15 business days. Expedited review (for medical urgency) takes 72 hours. Start renewal requests 60-90 days before current authorization expires.

What if Eloctate isn't on UnitedHealthcare's preferred formulary? You'll likely need to try a preferred factor VIII product first (step therapy) or provide strong medical justification for why alternatives failed or are contraindicated.

Can I request an expedited appeal in Washington? Yes, if your hematologist documents that standard timelines would seriously jeopardize your health due to bleeding risk. Expedited appeals get decided within 72 hours.

Does step therapy apply if I've used Eloctate successfully outside Washington? Previous successful therapy can support an exception request, but you'll need documentation of your treatment history and any adverse reactions to preferred alternatives.

What's the difference between J7205 and NDC billing? J7205 is used for medical benefit claims (clinic administration) while NDC-only billing applies to pharmacy benefit (home infusion). Most routine Eloctate prophylaxis uses pharmacy benefit.

How do I calculate if I'm over the 40,250 unit monthly limit? Multiply your per-dose units by doses per month. Example: 3,500 IU every 4 days = ~26,250 units/month (within limit). If over, work with your hematologist to adjust scheduling.

From our advocates: We've seen many Washington patients successfully overturn initial Eloctate denials by ensuring their hematologist included specific bleeding frequency data and factor VIII recovery studies in the appeal. The key is showing that standard factor VIII products either failed to prevent bleeds or caused adverse reactions—concrete clinical evidence that reviewers can't ignore.

Disclaimer: This information is for educational purposes and doesn't constitute medical advice. Always consult your healthcare provider for medical decisions. For official appeals guidance, contact the Washington Office of Insurance Commissioner at 1-800-562-6900.

Sources & Further Reading

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