By Counterforce Health Team in Jaypirca (pirtobrutinib) —

Coding That Helps Get Jaypirca (Pirtobrutinib) Approved by Aetna (CVS Health) in Washington: ICD-10, HCPCS J-Code, and NDC Guide

Answer Box: Getting Jaypirca (Pirtobrutinib) Approved by Aetna (CVS Health) in Washington

Key codes needed: ICD-10 C83.1 (mantle cell lymphoma) or C91.1/C83.0 (CLL/SLL) with relapse status; HCPCS J9399; NDC varies by strength. Fastest approval path: Submit prior authorization through CVS Caremark with complete documentation of BTK inhibitor failure and current disease status. Start today: Gather diagnosis codes, prior therapy records, and current clinical notes. Most approvals come within 30-45 days with proper coding.

Table of Contents

  1. Medical vs. Pharmacy Benefit Pathways
  2. ICD-10 Coding for Jaypirca Eligibility
  3. Product Coding: HCPCS, J-Codes, and NDC Numbers
  4. Clean Prior Authorization Request Anatomy
  5. Common Coding Pitfalls and How to Avoid Them
  6. Verification with Aetna (CVS Health) Resources
  7. Pre-Submission Audit Checklist
  8. Appeals Process for Washington Residents
  9. FAQ: Jaypirca Coding and Coverage

Medical vs. Pharmacy Benefit Pathways

Jaypirca (pirtobrutinib) typically falls under specialty pharmacy benefit rather than medical benefit because it's an oral medication taken at home. Understanding this distinction is crucial for proper billing and approval.

Pharmacy Benefit Path (Most Common)

  • Coverage through: CVS Caremark specialty pharmacy division
  • Prior authorization required: Yes, for most Aetna plans
  • Billing code: HCPCS J9399 for reimbursement tracking
  • NDC required: Specific to tablet strength prescribed
  • Typical copay: Specialty tier (often $100-500+ monthly)

Medical Benefit Path (Rare)

  • When applicable: If administered in clinical setting (uncommon for oral drugs)
  • Coverage through: Aetna medical benefits
  • Billing: Through provider claims with J-code
  • Prior authorization: Still typically required
Note: Most oral oncology drugs like Jaypirca are covered under pharmacy benefits, even when they require prior authorization similar to medical benefit drugs.

ICD-10 Coding for Jaypirca Eligibility

Accurate diagnosis coding is essential for Jaypirca approval. The medication is FDA-approved for specific blood cancers with documented prior treatment failure.

Mantle Cell Lymphoma (MCL)

Primary code: C83.1 - Mantle cell lymphoma Required specificity: Add fifth character for anatomical site:

  • C83.10 - Unspecified site
  • C83.11 - Lymph nodes of head, face, and neck
  • C83.12 - Intrathoracic lymph nodes
  • C83.13 - Intra-abdominal lymph nodes
  • C83.14 - Lymph nodes of axilla and upper limb
  • C83.15 - Lymph nodes of inguinal region and lower limb
  • C83.16 - Intrapelvic lymph nodes
  • C83.17 - Spleen
  • C83.18 - Lymph nodes of multiple sites
  • C83.19 - Extranodal and solid organ sites

Chronic Lymphocytic Leukemia (CLL)

Primary code: C91.1 - Chronic lymphocytic leukemia of B-cell type Required documentation: Must specify remission status for prior authorization

Small Lymphocytic Lymphoma (SLL)

Primary code: C83.0 - Small cell B-cell lymphoma Site specificity: Same fifth-character requirements as mantle cell lymphoma

Documenting Relapsed/Refractory Status

Critical for Jaypirca approval - must document:

  • Previous BTK inhibitor therapy: Include drug names, dates, duration
  • Reason for discontinuation: Disease progression, intolerance, or toxicity
  • Current disease status: Active disease requiring treatment
  • For CLL/SLL: Prior BCL-2 inhibitor exposure may be required per plan

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

HCPCS J-Code

Jaypirca HCPCS code: J9399 (Not otherwise classified, antineoplastic drug, oral)

This is a "not otherwise classified" code used for newer oral oncology drugs that don't have specific J-codes yet. Include drug name and NDC in claims.

NDC Numbers by Strength

Jaypirca is available in two tablet strengths with corresponding NDC codes:

Strength Package Size NDC Number
50 mg tablets 60-count bottle (verify with current prescribing information)
100 mg tablets 60-count bottle (verify with current prescribing information)
Important: NDC numbers can change with manufacturing updates. Always verify current NDCs with the FDA Orange Book or manufacturer resources.

Dosing and Units

Standard dosing: 200 mg once daily Unit conversion:

  • 200 mg daily = 2 × 100 mg tablets OR 4 × 50 mg tablets
  • Monthly supply = 30-day quantity
  • 90-day supply often available for maintenance therapy

Clean Prior Authorization Request Anatomy

A complete prior authorization request includes these essential elements:

Patient Information Section

  • Full name, date of birth, member ID
  • Prescribing physician details and NPI
  • Diagnosis with ICD-10 codes (include all relevant codes)
  • Current weight and BSA if relevant for dosing

Clinical Documentation

  • Primary diagnosis: ICD-10 code with anatomical site
  • Disease staging: Current stage and extent of disease
  • Prior treatments: Complete list with dates, duration, response, and reason for discontinuation
  • Current disease status: Active disease, symptoms, recent imaging or lab results
  • Treatment goals: Expected outcomes and monitoring plan

Prescription Details

  • Drug name: Jaypirca (pirtobrutinib)
  • Strength: 50 mg or 100 mg tablets
  • Dosing: 200 mg (specify tablet combination) once daily
  • Quantity: 30-day, 60-day, or 90-day supply
  • NDC number for prescribed strength
  • HCPCS code: J9399

Supporting Evidence

  • FDA approval indication alignment
  • Relevant clinical guidelines (NCCN, ASH, etc.)
  • Laboratory results supporting diagnosis
  • Imaging studies showing disease extent
  • Documentation of contraindications to alternative therapies

Common Coding Pitfalls and How to Avoid Them

Pitfall 1: Incomplete ICD-10 Specificity

Problem: Using C83.1 without anatomical site specification Fix: Always include the fifth character (C83.11, C83.12, etc.) Impact: Claims may be rejected for insufficient specificity

Pitfall 2: Missing Prior Treatment Documentation

Problem: Not documenting BTK inhibitor failure with specific details Fix: Include drug names, dates, duration, and specific reason for discontinuation Example: "Patient received ibrutinib 420mg daily from [date] to [date], discontinued due to disease progression confirmed by CT scan on [date]"

Pitfall 3: Incorrect Unit Calculations

Problem: Requesting wrong quantity for dosing regimen Fix: 200 mg daily = 60 tablets per 30 days (if using 100 mg strength) Verification: Always double-check quantity calculations before submission

Pitfall 4: Wrong Benefit Category

Problem: Submitting to medical benefit instead of pharmacy benefit Fix: Route through CVS Caremark specialty pharmacy for oral medications Check: Verify benefit category with member services before submission

Pitfall 5: Outdated NDC Numbers

Problem: Using superseded NDC codes from older references Fix: Verify current NDCs with manufacturer or FDA Orange Book Best practice: Check NDCs monthly for accuracy

Verification with Aetna (CVS Health) Resources

Before submitting any prior authorization, verify current requirements through official Aetna resources.

Key Verification Steps

  1. Check formulary status: Use Aetna's drug search tool
  2. Review coverage policy: Look for oncology or specialty drug policies
  3. Confirm submission method: CVS Caremark portal vs. fax submission
  4. Verify required forms: Some plans have specific PA forms for oncology drugs

Contact Resources

  • Aetna member services: Phone number on insurance card
  • CVS Caremark: 1-800-294-5979 for specialty medications
  • Provider services: Use provider portal or dedicated PA phone line
Tip: Save time by calling the provider-specific prior authorization line rather than general member services. They have access to clinical review criteria.

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed rebuttals. Their platform helps identify the specific denial basis and drafts point-by-point responses aligned to each plan's requirements, significantly improving approval rates for complex specialty medications like Jaypirca.

Pre-Submission Audit Checklist

Use this checklist to ensure your prior authorization request is complete before submission:

Documentation Review

  • ICD-10 codes include anatomical site specificity
  • All prior BTK inhibitor treatments documented with dates and outcomes
  • Current disease status clearly described with supporting evidence
  • Prescriber information complete with NPI number
  • Patient weight and BSA included if relevant for dosing

Coding Verification

  • HCPCS code J9399 included
  • Current NDC number verified for prescribed strength
  • Quantity calculation matches prescribed dosing regimen
  • Days supply clearly specified (30, 60, or 90 days)

Clinical Support

  • Recent labs or imaging supporting active disease
  • Documentation of contraindications to alternative therapies
  • Treatment goals and monitoring plan described
  • Relevant clinical guidelines referenced where applicable

Administrative Details

  • Correct benefit category identified (pharmacy vs. medical)
  • Appropriate submission method confirmed (portal, fax, mail)
  • Required forms completed per plan specifications
  • Contact information current for follow-up questions

Appeals Process for Washington Residents

If your initial prior authorization is denied, Washington state provides strong appeal protections with high success rates.

Internal Appeal Process

Timeline: File within 180 days of denial Success rate: Approximately 44% of internal appeals succeed Required: At least one internal appeal before external review How to file: Contact Aetna member services or use online portal

External Review (IRO)

Timeline: File within 4 months of final internal denial Cost: No cost to patients (insurers pay for external review) Success rate: Approximately 40% of external reviews overturn denials Contact: Washington State Office of the Insurance Commissioner at 1-800-562-6900

Expedited Reviews

When available: If health could be in serious jeopardy Timeline: Decisions within 72 hours for urgent cases How to request: Specify "expedited" when filing appeal

From our advocates: We've seen many Washington patients successfully overturn specialty drug denials by combining thorough clinical documentation with the state's robust external review process. The key is persistence - less than 1% of denied claims are appealed despite high success rates, so don't give up after an initial denial.

For complex appeals requiring detailed clinical rebuttals, Counterforce Health can help analyze your denial letter and create a targeted response that addresses the specific denial reasons while incorporating the clinical evidence and plan policies most likely to lead to approval.

FAQ: Jaypirca Coding and Coverage

Q: How long does Aetna (CVS Health) prior authorization take for Jaypirca in Washington? A: Standard decisions typically take 30-45 days. Expedited reviews for urgent cases can be completed within 72 hours if clinical urgency is documented.

Q: What if Jaypirca is non-formulary on my Aetna plan? A: You can request a formulary exception with documentation of medical necessity and failure of formulary alternatives. Many non-formulary oncology drugs are approved through this process.

Q: Can I request an expedited appeal if my initial prior authorization is denied? A: Yes, if your physician documents that delays could seriously jeopardize your health. Expedited appeals in Washington must be decided within 72 hours.

Q: Do I need to document BCL-2 inhibitor failure for all Jaypirca indications? A: BCL-2 inhibitor exposure requirements vary by indication and plan. For CLL/SLL, many plans require both BTK and BCL-2 inhibitor failure. Check your specific plan's coverage policy.

Q: What's the difference between HCPCS J9399 and a specific J-code? A: J9399 is a "not otherwise classified" code used for newer drugs without specific J-codes. Include the drug name and NDC number to ensure proper identification and billing.

Q: Can I appeal if my plan has a quantity limit that's less than my prescribed dose? A: Yes, quantity limit exceptions are available with clinical justification. Document the medical necessity for the specific dosing regimen prescribed.

Q: Does step therapy apply if I've failed BTK inhibitors outside of Washington? A: Prior treatment history from other states is generally accepted. Ensure you have complete documentation of previous therapies, including dates and reasons for discontinuation.

Q: What should I do if my NDC number is rejected during billing? A: Verify the NDC with the manufacturer or FDA Orange Book, as numbers can change with manufacturing updates. Contact CVS Caremark if the correct NDC continues to be rejected.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and is not medical advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. Coding and coverage policies may change; verify current requirements with official sources. For assistance with complex appeals, consider consulting with healthcare advocates or legal professionals specializing in insurance matters.

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