By Counterforce Health Team in Rapivab (peramivir) —

Coding That Helps Get Rapivab (Peramivir) Approved by Aetna CVS Health in Michigan: ICD-10, HCPCS J-Code, and NDC Guide

Answer Box: Getting Rapivab (Peramivir) Covered by Aetna CVS Health in Michigan

Rapivab (peramivir) requires proper medical benefit coding for Aetna CVS Health approval in Michigan. Use HCPCS J2547 (1 mg per unit), bill 600 units for standard adult dose, pair with ICD-10 J10.1 or J11.1 for uncomplicated influenza, and include NDC 61364-181-03 or 72769-181-03. Prior authorization typically requires documentation of symptom onset ≤48 hours and inability to use oral antivirals. If denied, file internal appeal within 180 days, then Michigan DIFS external review within 127 days for binding decision.

Next step: Contact your prescriber to verify exact coding requirements and submit prior authorization through Aetna's provider portal.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit
  2. ICD-10 Mapping for Influenza
  3. Product Coding: HCPCS J2547, NDC, and Units
  4. Clean Request Anatomy
  5. Frequent Coding Pitfalls
  6. Aetna CVS Health Verification
  7. Michigan Appeal Process
  8. Quick Audit Checklist
  9. FAQ

Coding Basics: Medical vs. Pharmacy Benefit

Rapivab (peramivir) always bills under the medical benefit, not pharmacy benefit, because it's administered via IV infusion in healthcare facilities. This distinction is crucial for Aetna CVS Health claims processing.

Key Differences:

  • Medical Benefit: Uses HCPCS J-codes, requires facility administration, includes infusion CPT codes
  • Pharmacy Benefit: Uses NDC-only billing, retail/specialty pharmacy dispensing, oral medications

For Rapivab, you'll need:

  • Drug code: HCPCS J2547 (injection, peramivir, 1 mg)
  • Administration code: CPT 96365 (IV infusion, initial up to 1 hour)
  • Revenue code: 0636 (drugs requiring detailed coding) for facility claims
Note: Aetna Better Health of Oklahoma lists Rapivab under medical benefit only, confirming this classification across Aetna plans.

ICD-10 Mapping for Influenza

Proper ICD-10 coding supports medical necessity for Rapivab's FDA-approved indication: acute uncomplicated influenza in patients ≥6 months.

Primary Codes:

  • J10.1: Influenza due to identified influenza virus with other respiratory manifestations
  • J11.1: Influenza due to unidentified influenza virus with other respiratory manifestations

Documentation Requirements:

  • Symptom onset: Document exact date/time (must be ≤48 hours for Rapivab efficacy)
  • Clinical presentation: Fever, cough, rhinorrhea, myalgia
  • Positive flu test: When available and required by plan policy
  • Complications ruled out: Use J10.1/J11.1 for uncomplicated cases; avoid J10.0/J11.0 (with pneumonia)
Tip: Aetna requires ICD-10 codes at highest level of specificity with full character count for valid claims.

Product Coding: HCPCS J2547, NDC, and Units

HCPCS J2547 Unit Calculation

Critical: J2547 represents 1 mg of peramivir, so billing units must equal total milligrams administered.

Patient Type Dose Billing Units
Adult standard 600 mg 600 units
Pediatric (12 mg/kg) Weight × 12 mg (max 600 mg) Weight × 12 units (max 600)
Renal impairment (CrCl 30-49) 200 mg 200 units
Renal impairment (CrCl 10-29) 100 mg 100 units

NDC Codes:

  • 61364-181-03: Carton of 3 × 200 mg/20 mL vials (legacy)
  • 72769-181-03: Current NDC format
  • 61364-181-01: Single 200 mg/20 mL vial

Vial vs. Units Distinction:

A 600 mg dose requires 3 vials (200 mg each) but bills as 600 units of J2547, not 3 units.

Clean Request Anatomy

Prior Authorization Template:

Patient: [Name], DOB, Aetna ID
Diagnosis: J11.1 - Influenza, unidentified virus, uncomplicated
Drug: Rapivab (peramivir) 600 mg IV × 1 dose
HCPCS: J2547 × 600 units
NDC: 72769-181-03
Administration: CPT 96365

Clinical Justification:
- Symptom onset: [Date/time] (≤48 hours)
- Unable to use oral antivirals due to: [nausea/vomiting/contraindication]
- Positive flu test: [Date, type]
- Medical necessity: [IV access required, severe symptoms]

Prescriber: [Name, NPI, DEA]
Facility: [Name, NPI]

Required Documentation:

  • Prescriber attestation of medical necessity
  • Chart notes showing symptom timeline
  • Prior antiviral failures/contraindications (if applicable)
  • Lab results (flu test, renal function if dose adjustment)

Frequent Coding Pitfalls

Most Common Errors:

  1. Unit Conversion: Billing 1 unit instead of 600 units for adult dose
  2. Wrong Benefit: Submitting to pharmacy benefit instead of medical
  3. Missing Administration: Forgetting CPT 96365 for infusion
  4. NDC Mismatch: Using incorrect or outdated NDC codes
  5. Revenue Code: Omitting 0636 on facility claims

Unit Calculation Mistakes:

  • Wrong: J2547 × 1 unit for "one dose"
  • Wrong: J2547 × 3 units for "three vials"
  • Correct: J2547 × 600 units for 600 mg dose
From our advocates: We've seen claims denied simply because providers billed 1 unit thinking it meant "one treatment course." Always remember that J2547 units equal milligrams administered—this single correction has helped reverse numerous denials.

Aetna CVS Health Verification

Coverage Confirmation:

  1. Check formulary: Log into Aetna member portal and search "Rapivab"
  2. Verify PA requirements: Contact CVS Caremark at member services number on ID card
  3. Confirm medical benefit: Rapivab should appear under medical, not pharmacy coverage

Plan-Specific Notes:

Counterforce Health can help streamline this verification process by analyzing your specific Aetna plan's requirements and identifying the exact documentation needed for approval. Our platform automatically checks formulary status, PA criteria, and coding requirements to reduce claim delays and denials.

Michigan Appeal Process

Timeline Overview:

Stage Deadline Decision Time Authority
Prior Authorization Submit promptly 15 days (72 hrs urgent) Aetna CVS Health
Internal Appeal 180 days from denial 30 days (72 hrs urgent) Aetna CVS Health
External Review 127 days from final denial 60 days (72 hrs urgent) Michigan DIFS

Internal Appeal Process:

  1. File through Aetna portal or mail appeal form
  2. Include new evidence addressing specific denial reasons
  3. Request peer-to-peer if clinical complexity warrants specialist discussion
  4. Document submission with tracking/confirmation numbers

Michigan DIFS External Review:

  • Free and binding on Aetna CVS Health
  • File online: Michigan DIFS External Review Request
  • Required documents: Denial letters, medical records, prescriber letter
  • Contact: 877-999-6442 for assistance
Tip: Michigan's 127-day deadline (vs. federal 120 days) gives you extra time, but don't wait—file promptly after final internal denial.

Quick Audit Checklist

Pre-Submission Review:

  • HCPCS J2547 with correct unit count (mg = units)
  • ICD-10 J10.1 or J11.1 for uncomplicated influenza
  • NDC 72769-181-03 or equivalent current code
  • CPT 96365 for IV administration
  • Revenue code 0636 for facility claims
  • Symptom onset ≤48 hours documented
  • Oral antiviral contraindication explained
  • Prior authorization submitted if required
  • NPI numbers for prescriber and facility
  • Member ID and demographics verified

Common Documentation Gaps:

  • Missing exact symptom onset time
  • Vague justification for IV vs. oral therapy
  • Incomplete renal function assessment for dosing
  • Absent positive flu test when required by plan

Counterforce Health's platform can automatically perform this pre-submission audit, catching coding errors and documentation gaps before claims are submitted, significantly reducing denial rates.

FAQ

How long does Aetna CVS Health prior authorization take in Michigan? Standard PA decisions are made within 15 calendar days, or 72 hours for urgent cases. If Aetna doesn't respond within these timeframes, the request is automatically approved under Michigan law.

What if Rapivab is non-formulary on my plan? Request a formulary exception by documenting medical necessity and why formulary alternatives aren't suitable. Include prescriber letter explaining clinical rationale and any prior antiviral failures.

Can I request an expedited appeal? Yes, if waiting for standard appeal timeline would seriously jeopardize your health. Your physician must provide a letter stating that delay would cause harm. Expedited appeals are decided within 72 hours.

What billing units do I use for pediatric patients? Calculate 12 mg/kg (maximum 600 mg), then bill that number as J2547 units. For example, a 30 kg child receives 360 mg, so bill J2547 × 360 units.

Does step therapy apply if I failed oral antivirals outside Michigan? Yes, document prior failures regardless of location. Include dates, specific medications tried, reasons for discontinuation, and prescriber notes from the treating physician.

How do I verify current NDC codes? Check the Rapivab ordering page or contact your distributor. Both legacy (61364-181-03) and current (72769-181-03) NDCs may be acceptable depending on your payer's requirements.

What happens if my external review is denied? Michigan DIFS external reviews are binding and final for medical necessity determinations. However, you may still have options for coverage appeals based on contract interpretation or administrative errors.

Can a family member file appeals for me? Yes, with written consent. Michigan law allows authorized representatives to file appeals on your behalf. Include a signed authorization form with your appeal submission.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions vary by individual plan and circumstances. Always consult with your healthcare provider and insurance company for specific guidance. For questions about Michigan insurance appeals, contact Michigan DIFS at 877-999-6442.

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