By Counterforce Health Team in Arcalyst (rilonacept) —

Get Arcalyst (Rilonacept) Covered by Aetna CVS Health in New York: Complete Coding, Billing & Appeals Guide

Answer Box: Quick Path to Arcalyst Coverage

Arcalyst (rilonacept) requires prior authorization from Aetna CVS Health for all FDA-approved indications. In New York, submit the CVS Caremark specialty PA form with diagnosis documentation (ICD-10 M04.2 for CAPS, I31.9 for recurrent pericarditis), prior therapy failures, and specialist consultation. If denied, file an internal appeal within 60 days, then request external review through NY Department of Financial Services within 4 months. Bill using HCPCS J2793 (1 unit = 1 mg) with modifier JB for subcutaneous administration.

Start today: Download the Aetna specialty drug PA form and gather clinical documentation of diagnosis and prior treatment failures.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit
  2. ICD-10 Mapping for Arcalyst Indications
  3. Product Coding: HCPCS, NDC, and Units
  4. Clean Prior Authorization Request
  5. Common Billing Pitfalls
  6. Aetna CVS Health Verification
  7. Appeals Process in New York
  8. Quick Audit Checklist

Coding Basics: Medical vs. Pharmacy Benefit

Understanding which benefit covers Arcalyst (rilonacept) determines your coding approach and submission pathway.

Medical Benefit Path:

  • Use when administered in clinical settings
  • Bill with HCPCS J-code J2793
  • Requires place of service codes
  • Often subject to buy-and-bill reimbursement

Pharmacy Benefit Path:

  • Use for patient self-administration
  • Bill with NDC codes 73604-914-01 or 73604-914-04
  • Processed through CVS Caremark Specialty
  • Requires specialty pharmacy coordination
Tip: Most Aetna CVS Health plans route Arcalyst through the specialty pharmacy benefit, making the pharmacy pathway more common for New York patients.

ICD-10 Mapping for Arcalyst Indications

Accurate diagnosis coding is critical for Arcalyst approval. Here are the primary ICD-10 codes:

Coverage at a Glance

Condition ICD-10 Code Documentation Requirements Notes
CAPS (all subtypes) M04.2 Genetic testing, clinical syndrome, family history Includes CINCA, Muckle-Wells, FCAS
DIRA M04.8 Genetic mutation, sterile osteomyelitis, pustulosis Use "other autoinflammatory syndromes"
Recurrent Pericarditis I31.9 or I30.0 Episode count, imaging, exclusion of secondary causes Document recurrence pattern

Documentation Words That Support Coding:

  • For CAPS: "cryopyrin-associated," "autoinflammatory," "periodic fever," "urticarial rash"
  • For DIRA: "interleukin-1 receptor antagonist deficiency," "sterile multifocal osteomyelitis"
  • For pericarditis: "recurrent," "idiopathic," "inflammatory markers elevated"

Product Coding: HCPCS, NDC, and Units

HCPCS J-Code Billing (Medical Benefit)

Primary Code: J2793 (rilonacept, 1 mg)

Unit Conversion:

  • Loading dose: 320 mg = 320 units
  • Maintenance dose: 160 mg weekly = 160 units
  • Pediatric dosing: 4.4 mg/kg (max 320 mg) = corresponding units

Required Modifiers:

  • JB: Subcutaneous administration (most common)
  • JW: Drug amount discarded/not administered (when applicable)

NDC Billing (Pharmacy Benefit)

Primary NDCs:

  • 73604-914-01: 220 mg single-use vial
  • 73604-914-04: 220 mg single-use vial (alternate packaging)

Clean Prior Authorization Request

Step-by-Step: Fastest Path to Approval

  1. Gather Clinical Documentation (Patient/Clinic)
    • Diagnosis confirmation with ICD-10 code
    • Prior therapy trials and outcomes
    • Laboratory results (inflammatory markers)
    • Specialist consultation notes
    • Timeline: 1-2 days
  2. Complete PA Form (Prescriber)
  3. Submit to CVS Caremark (Clinic Staff)
    • Fax: 1-866-237-5512 (CVS Caremark Specialty)
    • Phone: 1-800-294-5979
    • Electronic: Via Availity portal
    • Timeline: Same day
  4. Track Submission (Clinic/Patient)
    • Follow up within 2-3 business days
    • Document submission confirmation
    • Timeline: 24-72 hours for review

Clinician Corner: Medical Necessity Checklist

Essential Elements for Approval:

  • Confirmed diagnosis with appropriate ICD-10 code
  • Documentation of prior therapy failures:
    • CAPS/DIRA: Previous IL-1 inhibitors or immunosuppressants
    • Pericarditis: Colchicine, NSAIDs, corticosteroids
  • Specialist consultation (rheumatology, immunology, cardiology)
  • Baseline inflammatory markers (CRP, ESR)
  • Treatment goals and monitoring plan
  • FDA labeling citation or guideline reference

Common Billing Pitfalls

Frequent Errors and Solutions

Error Type Common Mistake Correct Approach Impact
Unit Conversion Billing 1 unit for 160 mg dose Bill 160 units (1 unit = 1 mg) Claim denial
Modifier Usage Missing JB for subcutaneous Always include JB modifier Processing delay
Place of Service Wrong POS for self-administration Use appropriate POS code Reimbursement issues
Documentation Insufficient prior therapy proof Document specific failures/intolerances PA denial

Counterforce Health: Streamlining Your Appeals

When facing complex denials or coding challenges, Counterforce Health helps patients and clinicians turn insurance denials into targeted, evidence-backed appeals. The platform automatically identifies denial reasons and drafts point-by-point rebuttals using payer-specific criteria and clinical evidence.

Aetna CVS Health Verification

How to Cross-Check Codes and Requirements

Before Submission:

  1. Verify Current Formulary Status
    • Check patient's specific plan formulary
    • Confirm tier placement and restrictions
    • Source: Aetna member portal or CVS Caremark
  2. Confirm PA Requirements
  3. Validate Coding Information
    • Confirm J-code and NDC accuracy
    • Check modifier requirements
    • Verify unit conversions

Appeals Process in New York

Internal Appeal (Aetna CVS Health)

Timeline: Must file within 60 days of denial Method: Call 1-800-294-5979 or submit written request Decision Time: 30 days for standard appeals

Required Documentation:

  • Original denial letter
  • Additional clinical evidence
  • Peer-reviewed literature support
  • Provider attestation letter

External Review (New York State)

If internal appeal is denied, New York law provides additional protection:

Eligibility: Medical necessity denials, experimental/investigational determinations Timeline: Request within 4 months of final adverse determination Process: File through NY Department of Financial Services Decision Time: 30 days standard, 72 hours expedited Cost: Maximum $25 (waived for financial hardship)

Note: New York's external review decisions are binding on insurers and have a strong track record of overturning denials for rare disease treatments with FDA approval.

Quick Audit Checklist

Pre-Submission Review:

  • Correct ICD-10 code matches diagnosis
  • HCPCS J2793 or appropriate NDC selected
  • Unit calculation matches prescribed dose
  • JB modifier included for subcutaneous administration
  • Prior therapy documentation complete
  • Specialist consultation included
  • Current PA form used
  • All required signatures present
  • Submission method confirmed (fax/portal)

Common Questions About Arcalyst Coverage

How long does Aetna CVS Health PA take in New York? Most prior authorizations are reviewed within 24-72 hours. Complex cases may take up to 5 business days.

What if Arcalyst is non-formulary on my plan? Request a formulary exception with clinical documentation. Non-formulary doesn't mean uncoverable—it requires additional justification.

Can I request an expedited appeal? Yes, if your health is at serious risk. Expedited appeals are decided within 72 hours in New York.

Does step therapy apply if I failed treatments outside New York? Yes, prior therapy failures from other states count toward step therapy requirements if properly documented.

What happens if my appeal is denied twice? You can request external review through the NY Department of Financial Services, which provides an independent medical review.

From Our Advocates

We've seen many Arcalyst denials overturned when providers include specific inflammatory marker trends (like CRP levels) and document the frequency of flares before treatment. One effective strategy is creating a timeline showing symptom patterns alongside lab values—this visual evidence often resonates with medical reviewers and demonstrates clear medical necessity.

Sources & Further Reading

Getting Arcalyst covered requires persistence and proper documentation, but New York's strong consumer protection laws provide multiple pathways to coverage. Counterforce Health specializes in turning denials into approvals by crafting evidence-based appeals that speak directly to payer criteria.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with healthcare providers and insurance representatives for specific coverage decisions. Coverage policies may change, and individual circumstances vary.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.