By Counterforce Health Team in Breyanzi (lisocabtagene maraleucel) —

How to Get Breyanzi (Lisocabtagene Maraleucel) Covered by Blue Cross Blue Shield in Georgia: Coding, Forms, and Appeals Guide

Answer Box: Getting Breyanzi Covered in Georgia

Blue Cross Blue Shield in Georgia requires prior authorization for Breyanzi (lisocabtagene maraleucel), a CAR-T therapy for relapsed/refractory B-cell cancers. Key steps: 1) Verify coverage using correct ICD-10 codes (C83.3 for DLBCL, C91.1 for CLL), 2) Submit PA request with clinical documentation showing ≥2 prior therapies failed, and 3) If denied, file internal appeal within 180 days, then external review within 60 days through Georgia DOI. Breyanzi costs ~$447,000-$487,000 and uses HCPCS code Q2054 for billing.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit
  2. ICD-10 Mapping for Breyanzi Coverage
  3. Product Coding: HCPCS, NDC, and Units
  4. Clean Prior Authorization Request
  5. Common Coding Pitfalls
  6. Verification with Blue Cross Blue Shield
  7. Appeals Process in Georgia
  8. Quick Pre-Submission Checklist

Coding Basics: Medical vs. Pharmacy Benefit

Breyanzi (lisocabtagene maraleucel) is always billed under the medical benefit, not pharmacy, due to its complex preparation and inpatient administration requirements. This CAR-T therapy requires specialized handling, lymphodepleting chemotherapy, and intensive monitoring at certified facilities.

Why Medical Benefit Matters:

  • Higher prior authorization scrutiny
  • Different deductibles and copayments
  • Site-of-care restrictions (REMS-certified centers only)
  • More detailed clinical documentation requirements

Blue Cross Blue Shield in Georgia follows this standard across all their plans, including Anthem Blue Cross Blue Shield which serves as the largest insurer in the state with approximately 33% market share.

ICD-10 Mapping for Breyanzi Coverage

Accurate diagnosis coding is critical for Breyanzi approval. Use the most specific codes available and document disease status clearly.

Primary ICD-10 Codes

Large B-Cell Lymphoma (LBCL):

  • C83.3: Diffuse large B-cell lymphoma (specify anatomical site)
  • C83.39: Diffuse large B-cell lymphoma, extranodal and solid organ sites
  • C83.3A: Diffuse large B-cell lymphoma, in remission (effective October 2025)

Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma:

  • C91.1: Chronic lymphocytic leukemia of B-cell type
  • C83.0: Small cell B-cell lymphoma (for SLL presentation)
  • C83.0A: Small cell B-cell lymphoma, in remission (new 2025 code)

Documentation Requirements for Medical Necessity

Your clinical documentation must support these key elements:

Disease Status:

  • Active, relapsed, or refractory disease (do not use remission codes)
  • Specific histologic subtype confirmation
  • Prior treatment history with dates and outcomes
  • Evidence of ≥2 prior systemic therapies for LBCL
  • For CLL/SLL: prior BTK inhibitor and BCL-2 inhibitor exposure

Supporting Documentation:

  • Pathology reports with CD19 expression
  • Imaging showing disease progression or persistence
  • Performance status assessment
  • Organ function studies
  • Infection screening results
Tip: Blue Cross Blue Shield Georgia requires documentation that the patient meets FDA-approved indications. Include specific line numbers and treatment dates in your submission.

Product Coding: HCPCS, NDC, and Units

HCPCS Code and Billing Units

Primary Code: Q2054

  • Description: "Lisocabtagene maraleucel, up to 110 million autologous anti-CD19 CAR-positive viable T cells, including leukapheresis and dose preparation procedures, per therapeutic dose"
  • Units: Report 1 unit per therapeutic dose (not per cell count or vial)
  • Effective: October 1, 2021 (replaces transitional J-codes)

NDC Numbers

Breyanzi NDC Codes:

  • 73153-0901-08 (CD8 component)
  • 73153-0902-04 (CD4 component)
  • 73153-0900 (complete kit)
  • Manufacturer: Juno Therapeutics, Inc.

Required Modifiers

Apply these modifiers based on your billing scenario:

  • -JZ: Required for Medicare Part B when no drug is discarded
  • -KX: May be required for CAR-T infusion procedure (0540T)
  • -TB: Required for 340B-acquired drugs under Medicare OPPS (effective January 2025)

Procedure Codes for Infusion

Use these ICD-10-PCS codes for the infusion procedure:

  • XW033N7 or XW043N7 depending on approach

Clean Prior Authorization Request

Coverage Requirements Table

Requirement Blue Cross Blue Shield Georgia Criteria Documentation Needed
Prior Authorization Required for all indications Complete PA form with clinical notes
Eligible Diagnoses LBCL after ≥2 lines; CLL/SLL after ≥2 lines including BTK and BCL-2 inhibitors Pathology report, treatment history
Site of Care REMS-certified facility only Facility certification documentation
Performance Status Adequate per treating physician ECOG or Karnofsky score documentation
Organ Function Adequate cardiac, pulmonary, renal, hepatic function Laboratory results and cardiac assessment

Medical Necessity Letter Components

When submitting your prior authorization, include a comprehensive medical necessity letter addressing:

Patient-Specific Factors:

  1. Confirmed diagnosis with histology and staging
  2. Complete prior treatment history with specific agents, dates, and response
  3. Reason for treatment failure or intolerance
  4. Current disease status and progression
  5. Performance status and organ function assessment
  6. Contraindications to alternative therapies

Clinical Evidence:

  • FDA approval for the specific indication
  • Published efficacy data for similar patient populations
  • Institutional treatment protocols
  • Multidisciplinary team recommendation
From our advocates: We've seen the strongest approvals when providers include a timeline showing each prior therapy with specific start/stop dates and reason for discontinuation. Blue Cross Blue Shield reviewers want to see clear evidence that standard therapies have been exhausted before approving CAR-T therapy.

Common Coding Pitfalls

Frequent Errors to Avoid

1. Wrong HCPCS Code

  • ❌ Using J3490, J3590, or J9999 (outdated transitional codes)
  • ✅ Always use Q2054 for Breyanzi

2. Incorrect Unit Calculation

  • ❌ Reporting multiple units based on cell count
  • ✅ Report exactly 1 unit per therapeutic dose

3. Missing Modifiers

  • ❌ Omitting required -JZ modifier for Medicare
  • ✅ Apply all applicable modifiers based on payer and setting

4. ICD-10 Code Mismatches

  • ❌ Using remission codes for active disease
  • ❌ Generic lymphoma codes when specific subtypes are documented
  • ✅ Use most specific code matching the pathology report

5. Incomplete NDC Documentation

  • ❌ Missing NDC numbers on claim forms
  • ✅ Include appropriate NDC (73153-0901-08, 73153-0902-04, or 73153-0900)

Verification with Blue Cross Blue Shield

Pre-Submission Verification Steps

1. Confirm Member Eligibility

  • Verify active coverage and benefits
  • Check if specialty pharmacy benefits apply
  • Confirm deductible and coinsurance amounts

2. Review Current Formulary Status

  • Access the most recent formulary document
  • Check for any quantity limits or step therapy requirements
  • Verify prior authorization requirements haven't changed

3. Validate Coding Requirements

  • Cross-reference HCPCS codes with current Blue Cross Blue Shield policies
  • Confirm NDC numbers match approved products
  • Verify modifier requirements for your specific plan type

4. Check Facility Requirements

  • Confirm REMS certification is current
  • Verify facility is in-network for Blue Cross Blue Shield
  • Document any site-of-care restrictions

Blue Cross Blue Shield Georgia Resources

  • Provider Portal: Access current PA forms and submission guidelines
  • Utilization Management: Confirm current criteria and requirements
  • Member Services: Verify coverage details and benefit structure
Note: Blue Cross Blue Shield policies can vary between Georgia plans. Always verify requirements with the specific plan covering your patient.

Appeals Process in Georgia

If your initial prior authorization is denied, Georgia provides robust appeal rights through both internal and external review processes.

Internal Appeals Process

Timeline: File within 180 days of denial notice Process: Submit through Blue Cross Blue Shield's standard appeals process Required Documentation:

  • Complete denial notice
  • Additional clinical documentation addressing denial reasons
  • Updated medical necessity letter
  • Peer-reviewed literature supporting treatment choice

External Review in Georgia

Georgia's external review process provides an independent assessment when internal appeals fail.

Key Requirements:

  • Must file within 60 days of final internal denial
  • Available for medical necessity determinations
  • Conducted by Georgia Department of Insurance
  • Free to consumers
  • Binding on insurance company if approved

How to Request External Review:

  1. Complete Georgia DOI external review application
  2. Submit all relevant medical records and correspondence
  3. Include statement explaining why treatment is medically necessary
  4. Mail or fax to Georgia Department of Insurance Consumer Services

Contact Information:

  • Phone: 1-800-656-2298 (Georgia DOI Consumer Services)
  • Process: Standard review (30 business days) or expedited (72 hours for urgent cases)

Expedited Appeals

For urgent medical situations, you can request expedited review at both internal and external levels. Georgia allows concurrent expedited external review if delays pose serious health risks.

Quick Pre-Submission Checklist

Clinical Documentation ✓

  • Complete pathology report with histologic subtype
  • Staging and imaging studies
  • Prior treatment history with specific agents and dates
  • Documentation of treatment failure or intolerance
  • Current performance status assessment
  • Organ function studies (cardiac, pulmonary, renal, hepatic)
  • Infection screening results

Coding Verification ✓

  • Correct ICD-10 diagnosis code (C83.3, C91.1, etc.)
  • HCPCS code Q2054 with 1 unit
  • Appropriate NDC numbers included
  • Required modifiers applied (-JZ, -KX, -TB as applicable)
  • Procedure codes for infusion (XW033N7 or XW043N7)

Administrative Requirements ✓

  • Prior authorization form completed
  • Medical necessity letter addressing all criteria
  • Facility REMS certification documented
  • Member eligibility and benefits verified
  • Submission method confirmed (portal, fax, mail)

Appeal Preparation ✓

  • Copy of all submitted documentation retained
  • Denial notice reviewed for specific reasons
  • Timeline for appeals calculated and calendared
  • Additional supporting evidence identified

About Counterforce Health

Counterforce Health specializes in turning insurance denials into successful appeals for complex therapies like Breyanzi. Our platform analyzes denial letters, identifies the specific coverage criteria, and generates evidence-backed appeals that address each payer's requirements. We help patients, clinicians, and specialty pharmacies navigate the prior authorization process with targeted documentation that improves approval rates for high-cost specialty medications.

Frequently Asked Questions

How long does Blue Cross Blue Shield prior authorization take in Georgia? Standard prior authorization decisions are typically made within 15 business days. Expedited reviews for urgent cases must be completed within 72 hours under Georgia regulations.

What if Breyanzi is not on my Blue Cross Blue Shield formulary? You can request a formulary exception by demonstrating medical necessity and providing documentation that covered alternatives are inappropriate or have failed.

Can I get help with the appeals process in Georgia? Yes, contact the Georgia Department of Insurance Consumer Services at 1-800-656-2298 for free assistance with appeals and external reviews.

Does step therapy apply to Breyanzi in Georgia? Blue Cross Blue Shield may require documentation of prior therapy failures, but specific step therapy protocols vary by plan. Check your specific policy documents.

What's the success rate for Breyanzi appeals in Georgia? While specific data isn't available, external review processes nationally overturn insurance denials in favor of patients approximately 40-50% of the time when proper documentation is provided.

How much will Breyanzi cost me with Blue Cross Blue Shield? Costs depend on your specific plan benefits, deductibles, and coinsurance. The wholesale cost is approximately $447,000-$487,000, but your out-of-pocket expense will be limited by your plan's annual maximum.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and appeal processes may change. Always consult with your healthcare provider about treatment decisions and verify current requirements with your specific insurance plan. For personalized assistance with insurance appeals, consider consulting with Counterforce Health or a qualified healthcare advocate.

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