By Counterforce Health Team in Xospata (gilteritinib) —

Get Xospata (Gilteritinib) Covered by Blue Cross Blue Shield in Virginia: ICD-10 Codes, Prior Auth Forms, and Appeals Guide

Answer Box: Getting Xospata Covered in Virginia

To get Xospata (gilteritinib) covered by Blue Cross Blue Shield in Virginia, you'll need: (1) confirmed FLT3-mutated relapsed/refractory AML diagnosis with proper ICD-10 coding (C92.02 for relapsed AML), (2) prior authorization submission through Anthem's Availity portal with complete treatment history, and (3) medical necessity letter from your hematologist-oncologist. If denied, Virginia's Bureau of Insurance offers external review within 120 days—with expedited cancer treatment appeals decided in 72 hours.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit
  2. ICD-10 Mapping for AML Documentation
  3. Product Coding: NDC, HCPCS, and Units
  4. Clean Prior Authorization Request
  5. Common Coding Pitfalls
  6. Blue Cross Blue Shield Virginia Verification
  7. Pre-Submission Audit Checklist
  8. Appeals Process in Virginia
  9. Cost and Support Options

Coding Basics: Medical vs. Pharmacy Benefit

Xospata (gilteritinib) is an oral tablet that falls under the pharmacy benefit rather than the medical benefit for most Blue Cross Blue Shield plans. This means it's dispensed through specialty pharmacies and subject to formulary restrictions, not administered in clinics like IV chemotherapy.

Key Coverage Pathway:

  • Pharmacy Benefit: Xospata is typically covered under Part D or commercial prescription drug coverage
  • Prior Authorization Required: Most BCBS plans require PA for specialty oncology medications
  • Specialty Pharmacy: Usually dispensed through designated specialty pharmacy networks
Note: Unlike injectable chemotherapy drugs that fall under medical benefits, oral targeted therapies like Xospata require different documentation and coding approaches.

ICD-10 Mapping for AML Documentation

Accurate ICD-10 coding is crucial for Xospata approval. The specific code depends on your current disease status:

ICD-10 Code Description When to Use
C92.00 Acute myeloblastic leukemia, not having achieved remission Initial diagnosis, active disease
C92.01 Acute myeloblastic leukemia, in remission Currently in remission
C92.02 Acute myeloblastic leukemia, in relapse Relapsed disease (most common for Xospata)

Documentation Requirements:

  • Clear statement of relapsed or refractory AML status
  • FLT3 mutation test results (ITD or TKD subtypes)
  • Previous treatment history and outcomes
  • Current performance status and treatment goals

The FDA label specifically indicates Xospata for "relapsed or refractory acute myeloid leukemia with a FLT3 mutation."

Product Coding: NDC, HCPCS, and Units

NDC Codes for Xospata:

  • NDC 0469-1425-21: 21 tablets per bottle
  • NDC 0469-1425-90: 90 tablets per bottle (30-day supply at 120mg daily)

Billing Format:

  • Use 11-digit NDC: 00469-1425-90 for most claims
  • Standard dosing: 120mg once daily (three 40mg tablets)
  • Monthly supply: 90 tablets

HCPCS Considerations: While Xospata doesn't have a specific J-code (as it's oral, not injectable), it may be coded under general oral chemotherapy categories for certain billing scenarios. Most pharmacy claims use NDC codes directly.

Units Calculation:

  • 1 month = 90 tablets (30 days × 3 tablets daily)
  • 3 months = 270 tablets
  • Always verify quantity limits with your specific BCBS plan

Clean Prior Authorization Request

A complete prior authorization submission should include:

Required Clinical Documentation:

  1. Diagnosis confirmation with appropriate ICD-10 code (typically C92.02)
  2. FLT3 mutation test results from FDA-approved testing
  3. Complete treatment history including dates, agents used, and reasons for discontinuation
  4. Medical necessity letter from hematologist-oncologist
  5. Current labs and imaging supporting relapsed/refractory status

Submission Process:

  • Submit through Anthem's Availity portal or call Provider Services at 800-901-0020
  • Include all supporting documentation in initial submission
  • Expect 5-14 business days for standard review
Tip: Contact your BCBS plan's specialty pharmacy team early in the process—they can guide you through specific requirements and help avoid common delays.

Common Coding Pitfalls

Frequent Documentation Errors:

  • Missing FLT3 mutation results: Must include specific subtype (ITD or TKD)
  • Incomplete treatment history: Document all prior therapies, not just recent ones
  • Wrong ICD-10 code: Using C92.00 instead of C92.02 for relapsed disease
  • Non-specialist prescriber: BCBS often requires hematologist-oncologist prescribing
  • Inadequate medical necessity: Generic letters often get denied

Units and Quantity Issues:

  • Requesting 30 tablets instead of 90 for monthly supply
  • Not accounting for dose adjustments in quantity calculations
  • Missing NDC-to-billing unit conversions

Timeline Mistakes:

  • Starting PA process too late (allow 2-3 weeks)
  • Missing appeal deadlines (typically 180 days for commercial plans)
  • Not requesting expedited review for urgent cases

Blue Cross Blue Shield Virginia Verification

Before submitting, verify:

  • Current formulary status through Anthem provider portal
  • Specific PA requirements for your patient's plan
  • Preferred specialty pharmacy network
  • Any step therapy requirements

Key Contacts:

  • Provider Services: 800-901-0020
  • Prior Authorization: Available through Availity portal
  • Appeals: Submit through provider portal or member services

Counterforce Health helps streamline this verification process by analyzing your specific plan's requirements and identifying the most effective documentation strategy for Xospata approvals.

Pre-Submission Audit Checklist

Clinical Documentation ✓

  • Confirmed relapsed/refractory AML diagnosis
  • FLT3 mutation test results (specify ITD or TKD)
  • Complete prior treatment chronology
  • Current disease status and imaging
  • Prescriber credentials (hematology-oncology)

Coding Accuracy ✓

  • Correct ICD-10 code (usually C92.02)
  • Accurate NDC (00469-1425-90 for 90-count)
  • Proper quantity calculation (90 tablets/month)
  • Appropriate billing units

Administrative ✓

  • PA form completely filled out
  • All required signatures obtained
  • Supporting documents attached
  • Submission method confirmed (Availity portal)
  • Follow-up plan established

Appeals Process in Virginia

If your Xospata prior authorization is denied, Virginia offers robust appeal rights through the State Corporation Commission Bureau of Insurance.

Internal Appeals (First Step):

  • File with Blue Cross Blue Shield within 180 days of denial
  • Include additional clinical evidence and peer-reviewed literature
  • Request peer-to-peer review with medical director
  • Typical timeline: 30 days for standard, 72 hours for expedited

External Review (Second Step): Virginia's external review process is particularly patient-friendly for cancer treatments:

  • Timeline: File within 120 days of final internal denial
  • Special provision: For cancer treatments, you can skip internal appeals and go directly to external review
  • Decision timeframe: 45 days for standard, 72 hours for expedited
  • Cost: Free to patients
  • Contact: Virginia Bureau of Insurance at 1-877-310-6560

Required Forms:

  • Form 216-A (External Review Request)
  • Original denial letters
  • Complete medical records
  • Physician statement of medical necessity

The Virginia external review process has helped many patients access oncology medications after initial denials. Counterforce Health can help prepare compelling appeal documentation that addresses specific denial reasons with evidence-based rebuttals.

Cost and Support Options

Financial Assistance Programs:

  • Astellas Patient Assistance: Income-based free drug program
  • Xospata Copay Card: May reduce out-of-pocket costs for commercially insured patients
  • Leukemia & Lymphoma Society: Copay assistance grants up to $5,000 annually

Pricing Context: Xospata's wholesale acquisition cost is approximately $28,979 for a 30-day supply (90 tablets at 120mg daily). Patient out-of-pocket costs vary significantly based on:

  • Insurance plan formulary tier
  • Deductible and coinsurance amounts
  • Maximum out-of-pocket limits
  • Availability of manufacturer support

From Our Advocates

We've seen patients successfully appeal Xospata denials by focusing on three key elements: comprehensive FLT3 mutation documentation, detailed chronology of prior therapy failures with specific dates and reasons, and a compelling medical necessity letter that references FDA labeling and NCCN guidelines. The combination of thorough documentation and Virginia's patient-friendly external review process has helped many patients access this critical treatment.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual circumstances and specific insurance plans. Always consult with your healthcare team and insurance provider for personalized guidance.

Need Help? Virginia's Bureau of Insurance Consumer Services (1-877-310-6560) provides free assistance with insurance appeals and external reviews.

Sources & Further Reading

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