By Counterforce Health Team in Rapivab (peramivir) —

Getting Rapivab (Peramivir) Covered by Humana in New York: Coding, Appeals, and Prior Authorization Guide

Answer Box: Getting Rapivab (Peramivir) Covered by Humana in New York

Rapivab (peramivir) requires prior authorization from Humana Medicare Advantage plans in New York. Submit requests using HCPCS code J2547, proper ICD-10 codes (J09-J11 series), and documentation showing symptom onset within 48 hours plus inability to use oral antivirals. First step: Have your prescriber submit a PA request via Humana's provider portal or fax to 877-486-2621 with clinical justification. If denied, file an internal appeal within 60 days, then escalate through Medicare's federal appeals process (not New York State DFS, which excludes Medicare plans). Standard PA decisions take up to 72 hours; expedited reviews available for urgent cases.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit
  2. ICD-10 Mapping for Influenza
  3. Product Coding: HCPCS, J-Codes, and NDC
  4. Clean Prior Authorization Request
  5. Common Coding Pitfalls
  6. Verification with Humana Resources
  7. Appeals Process for New York Residents
  8. Quick Pre-Submission Checklist
  9. FAQ

Coding Basics: Medical vs. Pharmacy Benefit

Rapivab (peramivir) is an intravenous neuraminidase inhibitor that always falls under the medical benefit, not the pharmacy benefit. This distinction is crucial for New York patients with Humana coverage.

Medical Benefit Path:

  • Billed using HCPCS J-codes
  • Administered in clinical settings (hospital outpatient, physician office, emergency department)
  • Covered under Medicare Part B (not Part D)
  • Requires proper revenue codes for facility billing

Why This Matters:

  • Medicare Part D plans will deny IV-administered drugs like Rapivab
  • Prior authorization requests must go through medical benefit channels
  • Billing errors can result in claim denials and patient responsibility for full costs (~$900-$1,000)
Note: Counterforce Health specializes in turning insurance denials into targeted appeals by identifying the specific denial basis and crafting evidence-backed rebuttals aligned to each plan's requirements.

ICD-10 Mapping for Influenza

Proper diagnosis coding is essential for Humana prior authorization approval. Use the most specific code based on your clinical documentation:

Primary ICD-10 Codes for Acute Uncomplicated Influenza

Virus Type ICD-10 Code When to Use
Novel influenza A (H1N1, avian flu) J09.X During outbreaks of identified novel strains
Other identified influenza (Type A/B/C) J10 Lab-confirmed non-novel influenza
Unidentified influenza virus J11 Clinical diagnosis without lab confirmation

Documentation Requirements

Your medical record must include:

  • Symptom onset timing (critical for 48-hour window)
  • Clinical presentation (fever, cough, myalgia, fatigue)
  • Influenza test results (if available)
  • Risk factors justifying IV therapy over oral options
  • Contraindications to oral/inhaled antivirals
Tip: Document specific reasons why oseltamivir (Tamiflu) or zanamivir (Relenza) aren't appropriate—this addresses Humana's step therapy requirements.

Product Coding: HCPCS, J-Codes, and NDC

HCPCS J-Code for Rapivab

  • Primary code: J2547 (Injection, peramivir, 1 mg)
  • Standard adult dose: 600 mg = 600 units for billing
  • Pediatric dosing: 12 mg/kg (maximum 600 mg)

NDC Codes

  • 61364-181-03: 200 mg/20 mL single-use vial
  • 61364-181-01: Alternative packaging

Revenue Codes for Facility Billing

  • 0636: Drugs requiring detailed coding (most common)
  • 0250: Pharmacy
  • 0260: Intravenous therapy
  • 0450: Emergency room (if applicable)

Administration Billing

Separately bill for IV administration using:

  • CPT 96365: Initial IV infusion (15-30 minutes for Rapivab)

Clean Prior Authorization Request

Required Documentation Package

Clinical Information:

  1. Diagnosis: ICD-10 code with supporting symptoms
  2. Timing: Document symptom onset within 48 hours
  3. Medical necessity: Why IV route is required
  4. Prior therapies: Previous antiviral use or contraindications
  5. Patient factors: Age, comorbidities, pregnancy status

Coding Elements:

  • HCPCS: J2547
  • NDC: 61364-181-03 or 61364-181-01
  • Units: Match exact mg dose (typically 600 units for adults)
  • Revenue code: 0636
  • Administration: CPT 96365

Sample Medical Necessity Statement

"Patient presents with acute influenza (J11) with symptom onset 36 hours ago. Unable to tolerate oral oseltamivir due to severe nausea and vomiting. High-risk patient (age 67, diabetes, COPD) requiring prompt antiviral therapy. IV peramivir 600 mg × 1 dose requested per FDA labeling for patients unable to use oral therapy."

Common Coding Pitfalls

Unit Conversion Errors

  • Mistake: Billing 1 unit instead of 600 units for standard adult dose
  • Fix: J2547 represents 1 mg, so 600 mg = 600 units

Missing Revenue Codes

  • Mistake: Omitting facility revenue codes
  • Fix: Always include 0636 for drugs requiring detailed coding

Wrong Benefit Category

  • Mistake: Submitting to Medicare Part D instead of Part B
  • Fix: IV drugs are medical benefit only

Incomplete NDC Information

  • Mistake: Using only J-code without NDC
  • Fix: Include both J2547 and specific NDC (61364-181-03)

Timing Documentation Gaps

  • Mistake: Vague symptom onset documentation
  • Fix: Specific date/time of symptom onset within 48-hour window

Verification with Humana Resources

Pre-Submission Verification

  1. Check current formulary status on Humana's provider portal
  2. Confirm PA requirements for your specific plan type
  3. Verify submission methods:
    • Online: Humana provider portal
    • Fax: 877-486-2621
    • Phone: 800-555-CLIN (800-555-2546)

Cross-Reference Tools

Appeals Process for New York Residents

Important: New York State's Department of Financial Services (DFS) external appeal process does not apply to Medicare plans, including Humana Medicare Advantage. You must use the federal Medicare appeals process.

Internal Appeal with Humana

Timeline: 60 days from denial notice Method: Submit via:

  • Humana member portal
  • Written appeal to address on denial letter
  • Phone: Number on member ID card

Required Documents:

  • Original denial letter
  • Prescriber's medical necessity statement
  • Supporting clinical documentation
  • Updated lab results or imaging (if applicable)

Federal Medicare Appeals Process

If Humana upholds the denial:

  1. Redetermination (Level 1): Independent review by Humana
  2. Reconsideration (Level 2): Independent Review Entity
  3. Administrative Law Judge: For amounts ≥$200
  4. Medicare Appeals Council: Further escalation
  5. Federal District Court: Final level

Expedited Appeals: Available when standard timing could jeopardize health

  • Decision timeline: 24 hours for urgent drug requests
  • Qualification: Serious jeopardy to life, health, or maximum function
From our advocates: We've seen Humana approvals increase significantly when prescribers include specific contraindications to oral antivirals and document the 48-hour symptom onset window clearly. One common successful approach involves citing the patient's inability to keep oral medications down due to flu-related nausea, supported by nursing notes documenting vomiting episodes.

Quick Pre-Submission Checklist

Documentation Review

  • ICD-10 code matches clinical presentation
  • Symptom onset documented within 48 hours
  • Medical necessity for IV route explained
  • Prior oral antiviral failures or contraindications noted
  • Patient risk factors documented

Coding Verification

  • HCPCS J2547 included
  • NDC code specified (61364-181-03 or 61364-181-01)
  • Units calculated correctly (600 for standard adult dose)
  • Revenue code 0636 included
  • Administration code CPT 96365 added

Submission Details

  • Correct payer (Medicare Part B, not Part D)
  • Proper submission channel (provider portal/fax)
  • All required forms completed
  • Supporting documentation attached

When navigating complex prior authorization requirements, Counterforce Health helps patients and clinicians by analyzing denial letters, identifying specific policy gaps, and drafting targeted appeals with the right clinical evidence and procedural requirements.

FAQ

How long does Humana prior authorization take for Rapivab in New York? Standard PA requests receive decisions within 72 hours. Expedited requests for urgent cases get 24-hour turnaround when delay could jeopardize health.

What if Rapivab is non-formulary on my Humana plan? Request a formulary exception through your prescriber. They must submit a statement explaining why formulary alternatives aren't effective or cause adverse effects. Standard decision timeline is 72 hours.

Can I request an expedited appeal for Rapivab denial? Yes, if waiting for standard review could seriously jeopardize your health. Document why immediate treatment is critical and submit through expedited channels.

Does step therapy apply if I've tried other antivirals outside New York? Yes, document prior antiviral use regardless of location. Include details of previous oseltamivir or zanamivir trials, outcomes, and any adverse effects.

What's the difference between internal and external appeals for Humana Medicare? Internal appeals go through Humana's review process. External appeals for Medicare go through federal Medicare appeals system, not New York State DFS (which excludes Medicare plans).

How much does Rapivab cost without insurance approval? Cash prices typically range $900-$1,000 for a single 600 mg dose. Actual costs vary by facility and contracts.

What documentation helps most with Humana approvals? Clear documentation of symptom onset within 48 hours, specific contraindications to oral antivirals, and patient risk factors requiring prompt treatment.

Can I appeal to New York State if Humana denies Rapivab? No, Medicare plans (including Humana Medicare Advantage) are excluded from New York State DFS external appeals. Use the federal Medicare appeals process instead.

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 change over time. Always verify current requirements with Humana and consult healthcare providers for medical decisions. For personalized assistance with insurance appeals, contact Community Health Advocates at 888-614-5400 or visit Counterforce Health for specialized coverage support.

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