By Counterforce Health Team in Signifor / Signifor LAR (pasireotide) —

Getting Signifor LAR (Pasireotide) Covered by Blue Cross Blue Shield in Washington: Complete 2025 Coding, Prior Auth & Appeals Guide

Answer Box: Quick Path to Coverage

To get Signifor LAR covered by Blue Cross Blue Shield in Washington: First, identify your specific carrier (Premera Blue Cross or Regence BlueShield). Submit prior authorization using ICD-10 code E24.0 (Cushing's disease) or E22.0 (acromegaly), HCPCS J2502 for billing, and document failure/intolerance of surgery plus first-line treatments. If denied, appeal within 180 days using carrier-specific forms. Start by calling the number on your member card to request PA forms and current coverage policy.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit Paths
  2. ICD-10 Mapping for Signifor LAR
  3. Product Coding: HCPCS, J-Codes & NDC Overview
  4. Clean Prior Authorization Request Anatomy
  5. Frequent Coding Pitfalls to Avoid
  6. Verification with Blue Cross Blue Shield Resources
  7. Appeals Process for Washington
  8. Common Denial Reasons & How to Fix Them
  9. Quick Audit Checklist

Coding Basics: Medical vs. Pharmacy Benefit Paths

Signifor LAR (pasireotide) is typically covered under the medical benefit rather than pharmacy benefit due to its administration requirements. In Washington, most Blue Cross Blue Shield members are covered by either Premera Blue Cross or Regence BlueShield, each with distinct formularies and prior authorization processes.

Medical Benefit Coverage

  • HCPCS Code: J2502 (Injection, pasireotide long acting, 1 mg)
  • Billing Unit: 1 unit = 1 mg of drug administered
  • Site of Care: Physician office, hospital outpatient, or infusion center
  • Administration: Intramuscular injection by healthcare professional every 4 weeks

Why Medical Benefit Matters

Unlike oral medications processed through pharmacy benefits, Signifor LAR requires "buy-and-bill" or specialty pharmacy white bagging arrangements. This affects both prior authorization requirements and appeals processes.

Tip: Verify benefit coverage before ordering. Call the member services number on the insurance card and ask: "Is pasireotide covered under medical or pharmacy benefits?"

ICD-10 Mapping for Signifor LAR

Accurate diagnosis coding is critical for prior authorization approval. Signifor LAR has specific FDA-approved indications that must align with your ICD-10 codes.

Primary Diagnosis Codes

ICD-10 Code Description Documentation Requirements
E24.0 Pituitary-dependent Cushing's syndrome ACTH-dependent hypercortisolism, pituitary adenoma on imaging
E22.0 Acromegaly and pituitary gigantism Elevated IGF-1, elevated GH, pituitary adenoma

Supporting Secondary Codes

Always include complications and comorbidities that demonstrate disease severity:

  • E11.9 - Type 2 diabetes mellitus (common with both conditions)
  • I10 - Essential hypertension
  • M79.3 - Panniculitis (for Cushing's)
  • M25.50 - Pain in unspecified joint (acromegaly arthropathy)
  • G93.1 - Anoxic brain damage (if applicable from untreated disease)

Documentation Words That Support Coding

For Cushing's disease (E24.0), include these phrases in clinical notes:

  • "Biochemically confirmed hypercortisolism"
  • "24-hour urinary free cortisol elevated at [X] times upper limit of normal"
  • "ACTH-dependent Cushing's syndrome"
  • "Pituitary microadenoma/macroadenoma on MRI"

For acromegaly (E22.0), document:

  • "Age-adjusted IGF-1 elevated at [X] ng/mL (normal range [Y])"
  • "Mean growth hormone >1.0 mcg/L"
  • "Acral enlargement and soft tissue overgrowth"
  • "GH-secreting pituitary adenoma"

Product Coding: HCPCS, J-Codes & NDC Overview

Understanding proper coding prevents claim denials and speeds prior authorization approval.

HCPCS J2502 Billing Details

Signifor LAR dosing and corresponding units:

  • 10 mg dose = 10 units of J2502
  • 20 mg dose = 20 units of J2502
  • 40 mg dose = 40 units of J2502
  • 60 mg dose = 60 units of J2502

NDC Information

Each kit strength has a specific NDC for pharmacy claims:

  • Signifor LAR 10 mg kit: NDC 00078-0748-xx
  • Signifor LAR 20 mg kit: NDC 00078-0749-xx
  • Signifor LAR 40 mg kit: NDC 00078-0750-xx
  • Signifor LAR 60 mg kit: NDC 00078-0751-xx

(Verify exact 11-digit NDCs with current package labeling)

When Modifiers Apply

  • -JW: Drug amount discarded/not administered to patient
  • -JZ: Zero drug amount discarded/not administered to patient
  • -GA: Waiver of liability statement on file

Clean Prior Authorization Request Anatomy

A complete prior authorization request includes these essential elements:

Patient Information Section

Patient Name: [Full name]
DOB: [Date]
Member ID: [From insurance card]
Group Number: [From insurance card]
Phone: [Contact number]

Prescriber Information

Prescriber: [Full name, credentials]
NPI: [National Provider Identifier]
Specialty: Endocrinology
Address: [Complete address]
Phone/Fax: [Contact information]

Drug Request Details

Drug: Signifor LAR (pasireotide pamoate)
Strength: [10/20/40/60 mg]
Route: Intramuscular injection
Frequency: Every 4 weeks (28 days)
Quantity: 1 kit per 28 days
Duration: 12 months
HCPCS: J2502

Clinical Justification

  1. Primary diagnosis with ICD-10 code
  2. Failed prior therapies (surgery, radiation, medications)
  3. Current biochemical status (UFC for Cushing's, IGF-1/GH for acromegaly)
  4. Contraindications to preferred alternatives
  5. Treatment goals and monitoring plan

Frequent Coding Pitfalls to Avoid

Unit Conversion Errors

Wrong: Billing 1 unit of J2502 for a 40 mg dose
Correct: Billing 40 units of J2502 for a 40 mg dose

Mismatched Diagnosis Codes

Wrong: Using E24.9 (Cushing syndrome, unspecified) when pituitary source is confirmed
Correct: Using E24.0 (Pituitary-dependent Cushing's syndrome)

Missing Start Date Documentation

Always include:

  • Date of diagnosis confirmation
  • Date of prior therapy failures
  • Planned start date for Signifor LAR

Incomplete Prior Therapy Documentation

Document specific details:

  • "Failed octreotide LAR 40 mg monthly × 6 months (IGF-1 remained 2.1× ULN)"
  • "Surgery declined due to cavernous sinus invasion"
  • "Ketoconazole discontinued due to hepatotoxicity"

Verification with Blue Cross Blue Shield Resources

For Premera Blue Cross Members

  1. Provider Portal: Log into Availity for electronic prior authorization
  2. Drug Coverage: Check the Premera Covered Drugs portal
  3. PA Forms: Download from Premera's PA resource page

For Regence BlueShield/UMP Members

  1. Coverage Verification: Use Regence provider portal
  2. PA Requirements: Check UMP medication policies
  3. Forms: Access through HCA or Regence provider resources

Cross-Check Steps

  1. Verify member eligibility and benefits
  2. Confirm Signifor LAR is covered under medical benefit
  3. Download current prior authorization form
  4. Check for any step therapy requirements
  5. Verify appeals process and timelines

Appeals Process for Washington

Washington state provides strong consumer protections for insurance denials, including external review rights.

Internal Appeals Timeline

  • First-level appeal: 180 days from denial date to file
  • Standard review: 30 days for plan decision
  • Expedited review: 72 hours for urgent cases

Required Appeal Documentation

  1. Completed appeal form (carrier-specific)
  2. Clinical records supporting medical necessity
  3. Literature/guidelines supporting Signifor LAR use
  4. Provider letter detailing clinical rationale

External Review Process

After exhausting internal appeals, Washington residents can request independent external review:

  1. Request deadline: 180 days from final internal denial
  2. Process: Submit to Office of the Insurance Commissioner (OIC)
  3. Timeline: 30 days for standard review, 72 hours for expedited
  4. Contact: Washington OIC Consumer Advocacy at 1-800-562-6900
Note: External review decisions are binding on the insurance company.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
"Not medically necessary" Provide biochemical evidence of disease activity Current UFC (Cushing's) or IGF-1/GH (acromegaly) results
"Step therapy not met" Document failure/intolerance of required medications Detailed prior therapy notes with doses, durations, outcomes
"Experimental/investigational" Cite FDA approval and guidelines FDA prescribing information, endocrine society guidelines
"Non-formulary drug" Request formulary exception Medical necessity letter, contraindications to formulary alternatives
"Missing documentation" Submit complete clinical records Lab results, imaging reports, consultation notes

Scripts for Common Situations

For step therapy denials: "Patient has documented failure of octreotide LAR 40 mg monthly for 6 months with persistent IGF-1 elevation to 2.3× upper limit of normal despite optimal dosing. Pasireotide LAR represents the next appropriate therapeutic option per Endocrine Society guidelines."

For medical necessity challenges: "Cushing's disease with 24-hour urinary free cortisol of 180 mcg/24hr (normal <45) despite surgical resection attempt. Patient requires medical management to prevent cardiovascular and metabolic complications of persistent hypercortisolism."

Quick Audit Checklist

Before submitting your prior authorization request:

✓ Coding Verification

  • Correct ICD-10 code (E24.0 or E22.0)
  • Proper HCPCS code (J2502)
  • Accurate unit calculation (mg = units)
  • Supporting secondary diagnosis codes included

✓ Clinical Documentation

  • Primary diagnosis confirmed with biochemical evidence
  • Prior therapy failures documented with specifics
  • Contraindications to alternatives noted
  • Current disease activity demonstrated
  • Specialist prescriber identified

✓ Administrative Details

  • Complete member and prescriber information
  • Correct drug name, strength, and dosing
  • Appropriate quantity and duration
  • All required forms completed
  • Supporting documents attached

✓ Submission Process

  • Carrier-specific form used (Premera vs. Regence)
  • Electronic submission when available
  • Backup fax/mail method confirmed
  • Submission confirmation obtained
  • Follow-up timeline established

From Our Advocates

A composite tip from coverage advocates: "We've seen the highest success rates when providers include a clear timeline showing the progression from initial diagnosis through failed therapies to current Signifor LAR request. Payers want to see logical treatment sequencing, not just a list of medications tried. Include dates, doses, lab values, and specific reasons each therapy was discontinued."

Navigating Blue Cross Blue Shield prior authorization for Signifor LAR in Washington requires attention to coding details, thorough clinical documentation, and understanding of carrier-specific processes. Counterforce Health specializes in helping patients and providers turn insurance denials into successful appeals by creating evidence-backed, policy-aligned authorization requests. Their platform ingests denial letters, plan policies, and clinical notes to draft targeted rebuttals that address each payer's specific criteria.

Whether you're dealing with Premera Blue Cross or Regence BlueShield, the key is matching your clinical story to the payer's medical necessity criteria while ensuring all coding elements align properly. When denials occur, Washington's robust appeals process—including external review through independent organizations—provides additional pathways to coverage.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies vary by plan and change frequently. Always verify current requirements with your specific Blue Cross Blue Shield carrier and consult with qualified healthcare and legal professionals for guidance on your individual situation. For additional help with insurance appeals in Washington, contact the Office of the Insurance Commissioner at 1-800-562-6900.

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