By Counterforce Health Team in Poteligeo (mogamulizumab-kpkc) —

Coding That Helps Get Poteligeo (mogamulizumab-kpkc) Approved by Aetna (CVS Health) in Virginia: ICD-10, HCPCS J-Code, and Prior Authorization Guide

Quick Answer: Getting Poteligeo (mogamulizumab-kpkc) Covered

Poteligeo requires prior authorization from Aetna (CVS Health) for relapsed/refractory mycosis fungoides or Sézary syndrome. Use ICD-10 codes C84.0x (mycosis fungoides) or C84.1x (Sézary syndrome), HCPCS code J9204 (1 mg units), and document ≥1 prior systemic therapy failure. Submit via Aetna provider portal with pathology reports and treatment history. If denied, Virginia offers external review through the State Corporation Commission Bureau of Insurance within 120 days. Start today: Verify your exact ICD-10 code, gather prior therapy documentation, and check Aetna's current formulary status.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit
  2. ICD-10 Mapping for CTCL Subtypes
  3. Product Coding: HCPCS J9204 and NDC
  4. Clean Prior Authorization Anatomy
  5. Frequent Coding Pitfalls
  6. Verification with Aetna (CVS Health)
  7. Appeals Process in Virginia
  8. Quick Audit Checklist

Coding Basics: Medical vs. Pharmacy Benefit

Poteligeo (mogamulizumab-kpkc) is a physician-administered infusion covered under the medical benefit, not pharmacy. This means it's billed using HCPCS codes rather than NDC numbers on pharmacy claims.

Coverage Pathway

  • Medical Benefit: HCPCS J9204 for buy-and-bill administration
  • Site of Care: Hospital outpatient, infusion center, or clinic
  • Revenue Code: 0636 for hospital outpatient claims (CMS-1450)
  • Prior Authorization: Required by Aetna (CVS Health) for all plans
Note: Unlike oral medications that go through CVS Caremark pharmacy benefits, Poteligeo flows through Aetna's medical management team.

ICD-10 Mapping for CTCL Subtypes

Accurate diagnosis coding is critical for Poteligeo approval. Aetna's clinical policy requires specific CTCL subtypes.

Primary ICD-10 Codes

Diagnosis ICD-10 Code Documentation Requirements
Mycosis Fungoides C84.0x Pathology confirming cerebriform T-cells, CD4+ immunophenotype
C84.00 Unspecified site Use when specific anatomic involvement unclear
C84.01 Lymph nodes head/face/neck Document nodal biopsy or imaging
C84.08 Multiple lymph node sites Specify sites in clinical notes
C84.09 Extranodal/solid organ Include staging (ISCL/EORTC TNMB)
Sézary Syndrome C84.1x Blood work showing Sézary cells, flow cytometry
C84.10 Unspecified site Most common code for SS
C84.11 Lymph nodes head/face/neck Document hematologic involvement

Documentation Keywords That Support Coding

Include these phrases in clinical notes to strengthen your ICD-10 selection:

  • "Pathology-confirmed mycosis fungoides with cerebriform nuclei"
  • "CD4+ T-cell immunophenotype consistent with CTCL"
  • "Relapsed disease after [prior therapy name]"
  • "Progressive cutaneous lesions despite systemic treatment"
  • "Sézary cells >1000/μL confirming leukemic phase"

Product Coding: HCPCS J9204 and NDC

HCPCS Code Details

  • J9204: Injection, mogamulizumab-kpkc, 1 mg
  • Effective: October 1, 2019 (replaced J9999)
  • Billable Unit: 1 mg = 1 unit
  • NDC: 42747-0761-01 (20 mg/5 mL single-dose vial)

Dosing and Units Calculation

Standard Dosing: 1 mg/kg body weight IV

  • Cycle 1: Days 1, 8, 15, 22 (28-day cycle)
  • Subsequent cycles: Days 1, 15

Units Math Example (70 kg patient):

  • Total dose per infusion: 70 mg
  • Vials needed: 4 vials (70 mg ÷ 20 mg/vial = 3.5, round up)
  • Bill exactly: 70 units of J9204
  • Do not bill: 80 units (4 vials × 20 mg)

Modifier Usage

  • UD: For 340B hospitals billing at acquisition cost
  • JW: Drug amount discarded (document waste appropriately)

Clean Prior Authorization Anatomy

Required Elements for Aetna (CVS Health) PA

Patient Information:

  • Member ID and group number
  • Date of birth and policy effective dates
  • Prescribing physician NPI and specialty

Clinical Documentation:

  1. Pathology Report: Confirming MF or SS diagnosis
  2. Prior Therapy Summary: Drug names, dates, duration, outcomes
  3. Staging Information: ISCL/EORTC stage if available
  4. Treatment Plan: Dosing schedule, monitoring plan, site of care

Medical Necessity Letter Template:

Patient [Name] has pathology-confirmed [mycosis fungoides/Sézary syndrome] 
(ICD-10: [C84.0x/C84.1x]) that has relapsed after [number] prior systemic 
therapies including [drug names, dates, outcomes]. Per FDA labeling and 
NCCN guidelines, mogamulizumab-kpkc is indicated for relapsed/refractory 
CTCL after ≥1 prior systemic therapy. Planned dosing: 1 mg/kg IV on days 
1, 8, 15, 22 of cycle 1, then days 1, 15 of subsequent cycles.

Frequent Coding Pitfalls

Common Errors That Trigger Denials

Pitfall Impact Fix
Wrong ICD-10 Using C84.A0 (peripheral T-cell lymphoma, unspecified) instead of C84.0x Verify pathology report specifies MF/SS subtype
Unit Mismatch Billing vials (20 mg) instead of actual mg administered Calculate exact mg based on patient weight
Missing Prior Therapy No documentation of systemic treatment failures Include treatment summary with dates and outcomes
Incorrect Site Using C84.40 (mature T/NK-cell lymphomas) Confirm primary cutaneous origin in pathology
Date Errors Onset date before diagnosis date Cross-check pathology and clinical timeline

Weight Calculation Issues

  • Use actual body weight, not ideal body weight
  • Document weight in kg (convert from pounds: lbs ÷ 2.2 = kg)
  • Round dose to nearest mg for billing units

Verification with Aetna (CVS Health)

Pre-Submission Checklist

  1. Check Current Formulary Status
    • Log into Aetna provider portal (verify current link)
    • Search "mogamulizumab" or "Poteligeo"
    • Note tier status and PA requirements
  2. Verify Member Benefits
    • Call provider services: 1-888-632-3862
    • Confirm medical benefit coverage
    • Check site-of-care restrictions
  3. Review Current Policy

Cross-Reference Resources

  • CMS HCPCS: Verify J9204 is current for 2024
  • FDA Orange Book: Confirm NDC 42747-0761-01
  • NCCN Guidelines: Reference Category 1 recommendation for relapsed MF/SS

Appeals Process in Virginia

If Aetna (CVS Health) denies your Poteligeo request, Virginia offers robust appeal rights through the State Corporation Commission Bureau of Insurance.

Internal Appeal (First Step)

  • Timeline: File within 180 days of denial
  • Method: Aetna provider portal or written appeal
  • Decision: 30 days (72 hours if expedited)
  • Required: Additional clinical evidence, peer-to-peer review option

External Review (Virginia SCC)

  • Eligibility: After internal appeal completion
  • Timeline: Submit within 120 days of final denial
  • Form: Form 216-A (verify with SCC)
  • Decision: 45 days (72 hours if expedited)
  • Binding: Yes, on both patient and insurer

Contact Information

  • Email: [email protected]
  • Fax: (804) 371-9915
  • Mail: State Corporation Commission, Bureau of Insurance – External Review, P.O. Box 1157, Richmond, VA 23218

Quick Audit Checklist

Before Submitting PA or Claim

Diagnosis Coding:

  • ICD-10 matches pathology report (C84.0x or C84.1x)
  • Site-specific code selected when applicable
  • Documentation supports relapsed/refractory status

Product Coding:

  • J9204 units = exact mg administered (not vials used)
  • NDC 42747-0761-01 included with 11-digit format
  • Appropriate modifiers applied (UD, JW if applicable)

Clinical Support:

  • Prior systemic therapy documented with dates and outcomes
  • Pathology report confirms CTCL subtype
  • Weight documented in kg for dosing calculation
  • Medical necessity letter references FDA indication

Administrative:

  • Member eligibility verified
  • PA submitted through correct portal
  • All required attachments included
  • Prescriber specialty appropriate (oncology/hematology/dermatology)

Counterforce Health: Your Coverage Advocacy Partner

When dealing with complex prior authorizations like Poteligeo, having expert support can make the difference between approval and denial. Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned with each payer's specific requirements.

FAQ

How long does Aetna (CVS Health) PA take in Virginia? Standard prior authorizations take 15 business days. Expedited reviews (when medically urgent) are completed within 72 hours.

What if Poteligeo is non-formulary on my plan? Non-formulary drugs can still be covered through formulary exceptions. Submit medical necessity documentation showing why preferred alternatives aren't appropriate.

Does step therapy apply if I failed treatments in another state? Yes, prior therapy documentation from any U.S. provider is accepted. Include complete treatment records with dates and outcomes.

Can I request expedited appeal in Virginia? Yes, if your physician certifies that waiting could jeopardize your health. Virginia processes expedited external reviews within 72 hours.

What's the success rate for Poteligeo appeals? While specific data isn't published, Virginia's external review process overturns approximately 30-40% of denials when proper documentation is provided.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual circumstances, plan benefits, and current policies. Always verify requirements with your specific insurance plan and consult healthcare professionals for medical decisions. For personalized assistance with prior authorizations and appeals, consider working with coverage advocacy specialists like Counterforce Health.

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