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

Coding That Helps Get Poteligeo (mogamulizumab-kpkc) Approved in New York with Aetna (CVS Health): ICD-10, HCPCS J-Code, and NDC Requirements

Answer Box: Getting Poteligeo Covered by Aetna in New York

Key codes needed: ICD-10 C84.0x (mycosis fungoides) or C84.1x (Sézary syndrome), HCPCS J9204, NDC 42388-0302-01. Fastest path: Submit prior authorization with accurate weight-based dosing calculation (1 mg/kg), documented prior systemic therapy failure, and staging details. First step today: Verify patient's exact weight and gather pathology reports showing CTCL subtype. Appeals through New York DFS external review if denied, with 4-month deadline and potential $25 fee refund if you win.

Table of Contents

Coding Basics: Medical vs. Pharmacy Benefit

Poteligeo (mogamulizumab-kpkc) is exclusively covered under the medical benefit because it's administered intravenously in healthcare settings. This means:

  • Medical benefit pathway: Billed using HCPCS J-codes on professional claims (CMS-1500) or institutional claims (UB-04)
  • No pharmacy benefit option: Unlike oral medications, Poteligeo cannot be dispensed through retail or mail-order pharmacies
  • Site of care matters: Aetna typically requires administration in approved infusion centers or hospital outpatient departments
Note: Some plans may have "white bagging" or "brown bagging" policies where the specialty pharmacy ships directly to the infusion site, but the drug still bills under medical benefit using J-codes.

ICD-10 Mapping for CTCL

Accurate diagnosis coding is critical for Aetna prior authorization approval. Use the most specific code available based on your documentation:

Mycosis Fungoides (C84.0x)

  • C84.00 - Mycosis fungoides, unspecified site
  • C84.01 - Mycosis fungoides, lymph nodes of head, face and neck
  • C84.02 - Mycosis fungoides, intrathoracic lymph nodes
  • C84.03 - Mycosis fungoides, intra-abdominal lymph nodes
  • C84.04 - Mycosis fungoides, lymph nodes of axilla and upper limb
  • C84.05 - Mycosis fungoides, lymph nodes of inguinal region and lower limb
  • C84.06 - Mycosis fungoides, intrapelvic lymph nodes
  • C84.07 - Mycosis fungoides, spleen
  • C84.08 - Mycosis fungoides, lymph nodes of multiple sites
  • C84.09 - Mycosis fungoides, extranodal and solid organ sites
  • C84.0A - Mycosis fungoides, in remission

Sézary Syndrome (C84.1x)

  • C84.10 - Sézary syndrome, unspecified site
  • C84.11 - Sézary syndrome, lymph nodes of head, face and neck
  • C84.12 - Sézary syndrome, intrathoracic lymph nodes
  • C84.13 - Sézary syndrome, intra-abdominal lymph nodes
  • C84.14 - Sézary syndrome, lymph nodes of axilla and upper limb
  • C84.15 - Sézary syndrome, lymph nodes of inguinal region and lower limb
  • C84.16 - Sézary syndrome, intrapelvic lymph nodes
  • C84.17 - Sézary syndrome, spleen
  • C84.18 - Sézary syndrome, lymph nodes of multiple sites
  • C84.19 - Sézary syndrome, extranodal and solid organ sites
  • C84.1A - Sézary syndrome, in remission

Documentation Requirements for Coding

Your clinical notes must include:

  • Histological confirmation with pathology report
  • Disease staging (TNMB classification preferred)
  • Anatomic sites involved (skin, nodes, organs)
  • Blood involvement status (especially for Sézary syndrome)
  • Current disease status (active vs. remission)

Product Coding: HCPCS J9204 and NDC

HCPCS J-Code

J9204 - Injection, mogamulizumab-kpkc, 1 mg

  • Each billing unit = 1 mg of drug
  • Bill total mg administered (not per vial)
  • Effective for dates of service after October 1, 2019

NDC Code

42388-0302-01 - 20 mg/5 mL single-dose vial

  • Must include 11-digit NDC on all claims
  • Only NDC currently available for Poteligeo

Dosing and Units Calculation

Standard dose: 1 mg/kg based on actual body weight

Calculation steps:

  1. Total dose (mg) = Patient weight (kg) × 1 mg/kg
  2. Vials needed = Total dose (mg) ÷ 20 mg/vial (round UP to next whole vial)
  3. Billing units = Total dose administered in mg (use actual calculated dose, not rounded vial amount)

Example: 70 kg patient

  • Total dose = 70 mg
  • Vials needed = 70 ÷ 20 = 3.5, rounded up to 4 vials
  • Bill J9204 × 70 units (not 80 units for 4 vials)

Revenue Codes for Institutional Claims

  • 0636 - Drugs requiring detailed coding
  • Include both J9204 and NDC 42388-0302-01

Clean Request Anatomy

Here's what a complete prior authorization submission should include:

Patient Information Section

Patient: [Name], DOB: [Date]
Policy ID: [Aetna ID]
Diagnosis: Relapsed mycosis fungoides (C84.00)
Weight: 72 kg (verified [date])

Clinical Justification

INDICATION: Relapsed mycosis fungoides after failure of:
1. Methotrexate 15mg weekly × 6 months (progressive disease)
2. Bexarotene 300mg daily × 4 months (intolerable skin toxicity)

DOSING: Poteligeo 1 mg/kg (72 mg) IV
Schedule: Days 1, 8, 15, 22 of cycle 1, then days 1, 15 of subsequent cycles

Coding Section

ICD-10: C84.00 (Mycosis fungoides, unspecified site)
HCPCS: J9204 × 72 units per dose
NDC: 42388-0302-01
Site of care: Hospital outpatient infusion center

Supporting Documents

  • Pathology report confirming CTCL diagnosis
  • Staging workup (CT scans, flow cytometry if applicable)
  • Documentation of prior therapy failures
  • Current labs showing adequate organ function
  • ECOG performance status assessment

Frequent Pitfalls

Unit Conversion Errors

❌ Wrong: Billing 4 units for a 70 kg patient (thinking per vial) ✅ Right: Billing 70 units for a 70 kg patient (per mg administered)

Mismatched Codes

❌ Wrong: Using C84.4 (peripheral T-cell lymphoma) for mycosis fungoides ✅ Right: Using specific C84.0x code matching anatomic involvement

Missing Start Dates

❌ Wrong: "Patient has failed prior therapies" ✅ Right: "Methotrexate 1/2023-7/2023, bexarotene 8/2023-12/2023, both failed"

Incomplete Weight Documentation

❌ Wrong: Using estimated or historical weight ✅ Right: Current measured weight with date documented

NDC Format Errors

❌ Wrong: 42388-302-1 (10 digits) ✅ Right: 42388-0302-01 (11 digits with leading zeros)

Verification with Aetna Resources

Before submitting, cross-check your codes with these Aetna resources:

Prior Authorization Requirements

Check Aetna's clinical policy bulletin CPB 0940 for:

  • Current coverage criteria
  • Required documentation
  • Approved sites of care

Formulary Status

Verify through:

  • Aetna member portal formulary lookup
  • Provider portal prior authorization tool
  • CVS Caremark formulary (for specialty drugs)

Billing Guidelines

Confirm current requirements:

  • J-code coverage policies
  • NDC requirements for your specific plan type
  • Site of care restrictions

Pre-Submission Audit Checklist

Before submitting your prior authorization or claim:

Patient Eligibility

  • Aetna coverage verified and active
  • Specialty pharmacy benefits confirmed
  • Prior authorization required (yes for Poteligeo)

Clinical Documentation

  • Pathology report shows mycosis fungoides or Sézary syndrome
  • Disease staging documented
  • ≥1 prior systemic therapy documented with dates and outcomes
  • Current weight documented
  • ECOG performance status 0-1 documented
  • Adequate organ function labs within 30 days

Coding Accuracy

  • ICD-10 code matches documented disease sites
  • J9204 units calculated correctly (mg-based, not vial-based)
  • NDC 42388-0302-01 included in 11-digit format
  • Revenue code 0636 for institutional claims

Administrative Requirements

  • Prior authorization form completed
  • Prescriber attestation signed
  • Site of care meets Aetna requirements
  • All supporting documents attached

Appeals Process in New York

If Aetna denies your Poteligeo request, New York offers strong appeal rights:

Internal Appeal (Required First Step)

  • Timeline: 60 days from denial date to file
  • Aetna decision: 30 days (standard) or 72 hours (expedited)
  • Submit to: Aetna member/provider portal or address on denial letter

External Appeal Through New York DFS

  • Timeline: 4 months from final internal denial to file
  • DFS decision: 30 days (standard), 72 hours (expedited), 24 hours (urgent)
  • Fee: $25 (refunded if you win, waived for Medicaid/financial hardship)
  • Forms: New York DFS External Appeal Application

Getting Help

  • Community Health Advocates: 888-614-5400 (free assistance)
  • New York DFS Consumer Assistance: 800-400-8882
From our advocates: "We've seen Poteligeo denials overturned when families submitted comprehensive documentation showing the specific CTCL subtype, detailed prior treatment history with dates, and current staging workup. The key is matching your clinical story to Aetna's published criteria and using New York's external review process when needed."

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters, identifies the specific denial basis, and drafts point-by-point rebuttals using the right medical evidence and payer-specific workflows. For complex cases like Poteligeo coverage, having the right documentation strategy can make the difference between approval and denial.

FAQ

How long does Aetna prior authorization take for Poteligeo in New York? Standard decisions take 30-45 days, expedited reviews 72 hours. Medicare Part D plans must decide within 72 hours for standard requests.

What if Poteligeo is non-formulary on my Aetna plan? You can request a formulary exception with medical necessity documentation. Include evidence of prior therapy failures and clinical guidelines supporting use.

Can I request an expedited appeal if denied? Yes, if your doctor attests that delay would seriously jeopardize your health. Mark your appeal as "expedited" and include physician attestation.

Does step therapy apply if I failed treatments outside New York? Yes, prior therapy failures from any state count toward step therapy requirements if properly documented with dates and outcomes.

What counts as "prior systemic therapy" for Poteligeo coverage? Methotrexate, bexarotene, interferons, HDAC inhibitors, brentuximab vedotin, or chemotherapy. PUVA phototherapy does NOT count as systemic therapy.

How do I calculate billing units for a partial vial? Bill based on actual mg administered (patient's calculated dose), not the number of vials used. Waste documentation may be required for unused portions.

When working with complex specialty drug approvals, Counterforce Health helps patients and providers navigate the prior authorization process more effectively. Our evidence-based approach has helped secure coverage for challenging cases by ensuring all required documentation aligns with payer-specific criteria.

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 assistance with appeals and coverage issues, contact the New York Department of Financial Services or Community Health Advocates.

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