By Counterforce Health Team in Cabometyx (cabozantinib) —

How to Get Cabometyx (Cabozantinib) Covered by Blue Cross Blue Shield in California: Coding, Forms & Appeal Strategies

Answer Box: Getting Cabometyx Covered by Blue Cross Blue Shield California

Cabometyx (cabozantinib) requires prior authorization from Blue Cross Blue Shield California for all approved cancer indications. Submit through your specialty pharmacy with complete clinical documentation including ICD-10 diagnosis codes (C64.1/C64.2 for RCC, C22.0 for HCC, C73 for thyroid cancer), prior therapy failures, and FDA-approved indication support. If denied, file internal appeal within 180 days, then request California Independent Medical Review (IMR) through DMHC for binding external review. First step today: Verify your specific Blue Shield plan's specialty drug list and initiate prior authorization through your oncologist's office.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit Paths
  2. ICD-10 Mapping for Cabometyx Coverage
  3. Product Coding: HCPCS, NDC Numbers & Billing Units
  4. Clean Prior Authorization Request Anatomy
  5. Frequent Coding Pitfalls to Avoid
  6. Verification with Blue Cross Blue Shield Resources
  7. Pre-Submission Audit Checklist
  8. Appeals Process & Independent Medical Review
  9. FAQ: Common Cabometyx Coverage Questions

Coding Basics: Medical vs. Pharmacy Benefit Paths

Understanding whether Cabometyx falls under your specialty pharmacy benefit or medical benefit determines your coverage pathway and coding requirements with Blue Cross Blue Shield California.

Coverage at a Glance

Aspect Specialty Pharmacy Benefit Medical Benefit
Drug Type Self-administered oral tablets Office-administered (rare for Cabometyx)
Where Sourced Network specialty pharmacy only Provider/clinic obtains and bills
Billing Code NDC numbers, pharmacy claims HCPCS J9165 for medical claims
Prior Authorization Required through pharmacy benefit Required through medical management
Member Cost Specialty tier copay/coinsurance Medical deductible + coinsurance

For most patients: Cabometyx tablets are covered under the specialty pharmacy benefit, requiring fulfillment through Blue Shield's network specialty pharmacies and prior authorization submission via pharmacy channels.

ICD-10 Mapping for Cabometyx Coverage

Accurate ICD-10 coding is essential for medical necessity documentation. Blue Cross Blue Shield California requires diagnosis codes that align with FDA-approved Cabometyx indications.

Primary Diagnosis Codes

Cancer Type ICD-10 Code Documentation Requirements
Renal Cell Carcinoma C64.1 (right kidney)
C64.2 (left kidney)
C64.9 (unspecified)		 Must specify laterality; include histology (clear cell, papillary), stage, prior therapies
Hepatocellular Carcinoma C22.0 Pathology confirmation as HCC; prior sorafenib trial/failure documentation
Thyroid Cancer C73 Specify subtype (medullary, differentiated); RAI-refractory status for DTC
Critical: Always document laterality for renal cell carcinoma (right/left/unspecified). Missing laterality is a common denial reason and can delay appeals.

Supporting Documentation Language

When documenting medical necessity, include these key phrases that support proper coding:

  • "Advanced/metastatic [cancer type] confirmed by pathology"
  • "Prior therapy with [specific agent] resulted in progression/intolerance"
  • "Patient meets FDA criteria for cabozantinib treatment"
  • "NCCN Category 1 recommendation for this clinical scenario"

Product Coding: HCPCS, NDC Numbers & Billing Units

NDC Numbers by Tablet Strength

Strength NDC Number Typical Indication Billing Unit
20 mg 42388-0025-56 Dose reduction/pediatric DTC 1 tablet
40 mg 42388-0024-54 RCC combination therapy 1 tablet
60 mg 42388-0023-46 RCC monotherapy, HCC 1 tablet

HCPCS Coding for Medical Benefit

HCPCS Code: J9165 (Cabozantinib, oral, 1 mg)

  • Billing calculation: 60 mg daily dose = 60 units per day
  • Monthly supply: ~1,800 units (30 days × 60 mg)
Important: Do not substitute Cabometyx tablets with cabozantinib capsules (Cometriq). These are different formulations with distinct NDC numbers and indications.

Clean Prior Authorization Request Anatomy

Essential Components Checklist

1. Patient Demographics & Insurance

  • Blue Shield member ID and group number
  • Patient name, DOB, address matching insurance records
  • Prescribing physician NPI and contact information

2. Clinical Documentation

  • Diagnosis: ICD-10 code with laterality (if applicable)
  • Pathology report: Confirming cancer type and grade
  • Staging information: TNM staging, imaging dates
  • Prior therapies: Specific agents tried, dates, outcomes/reasons for discontinuation

3. Treatment Plan

  • Prescribed dose: 60 mg daily (RCC/HCC) or 40 mg daily (combination)
  • Duration: Until progression or unacceptable toxicity
  • Administration: On empty stomach, 1 hour before or 2 hours after eating
  • Monitoring plan: Regular labs, imaging schedule

4. Medical Necessity Justification

  • FDA indication match: Quote specific approved indication
  • Guideline support: Reference NCCN, ASCO, or other recognized guidelines
  • Patient-specific factors: Why alternatives are inappropriate

Frequent Coding Pitfalls to Avoid

Common Errors That Trigger Denials

1. Wrong Formulation Coding

  • Error: Using Cometriq (cabozantinib capsules) NDC for Cabometyx request
  • Fix: Verify NDC matches tablet formulation: 42388-002X-XX series

2. Missing Laterality Documentation

  • Error: Coding C64.9 (unspecified kidney) when laterality is known
  • Fix: Use C64.1 (right) or C64.2 (left) with supporting imaging/pathology

3. Incorrect Unit Calculations

  • Error: Billing 1 unit for 60 mg dose under J9165
  • Fix: Bill 60 units (1 mg per unit × 60 mg dose)

4. Specialty Pharmacy Bypass

5. Incomplete Prior Therapy Documentation

  • Error: Stating "patient failed prior therapy" without specifics
  • Fix: Document specific agents, dates, duration, and reason for discontinuation

Verification with Blue Cross Blue Shield Resources

Pre-Submission Verification Steps

1. Confirm Formulary Status

2. Review Prior Authorization Requirements

3. Confirm Network Specialty Pharmacy

  • Verify your preferred specialty pharmacy is in-network
  • Confirm they can handle Blue Shield PA submissions

4. Check Step Therapy Requirements

  • Review if your plan requires trial of preferred agents first
  • Gather documentation of contraindications or prior failures if applicable

Pre-Submission Audit Checklist

Final Review Before Submission

  • Patient eligibility verified through Blue Shield portal or phone
  • Correct NDC number matching prescribed tablet strength
  • ICD-10 code includes laterality (for RCC) and matches pathology
  • Prior authorization form completed with all required fields
  • Clinical notes include diagnosis, staging, prior therapies, rationale
  • Pathology report attached confirming cancer type
  • Imaging reports showing current disease status
  • Prior therapy documentation with specific agents, dates, outcomes
  • Prescription specifies "Cabometyx tablets" (not capsules)
  • Specialty pharmacy confirmed as in-network and ready to receive
  • Provider NPI and DEA numbers accurate on all forms
  • Member ID and group number match insurance card exactly

Appeals Process & Independent Medical Review

If your Cabometyx prior authorization is denied, California provides strong appeal rights with high success rates for well-documented oncology cases.

Step-by-Step Appeals Process

1. Internal Appeal (Required First Step)

  • Timeline: File within 180 days of denial notice
  • How to file: Submit through Blue Shield member portal or mail appeal form
  • Required documents: Denial letter, additional clinical evidence, physician letter
  • Decision timeline: 30 days for standard, 72 hours for expedited

2. Independent Medical Review (IMR)

  • When to file: After internal appeal denial or 30-day non-response
  • Authority: California Department of Managed Health Care (DMHC)
  • Process: Independent physician specialists review medical necessity
  • Timeline: 45 days standard, 7 days expedited
  • Cost: Free to patients
  • Decision: Binding on Blue Shield

Strengthening Your Appeal

Key strategies for success:

  • Address specific denial reasons point-by-point in your appeal letter
  • Include new clinical evidence not in original submission
  • Cite FDA labeling and treatment guidelines supporting use
  • Emphasize patient-specific factors making alternatives inappropriate
  • Request expedited review if treatment delay poses clinical risk
From our advocates: We've seen strong success when appeals include a detailed timeline showing disease progression on prior therapies, combined with peer-reviewed studies supporting cabozantinib's efficacy in the patient's specific clinical scenario. The key is making the medical necessity crystal clear to reviewers who may not be oncology specialists.

For IMR assistance, contact the DMHC Help Center at 888-466-2219 or file online at healthhelp.ca.gov.

FAQ: Common Cabometyx Coverage Questions

Q: How long does Blue Cross Blue Shield prior authorization take in California? A: Standard PA decisions are made within 14 business days. Expedited reviews (for urgent cases) are completed within 72 hours. Track status through your provider portal or by calling the PA department.

Q: What if Cabometyx isn't on my Blue Shield formulary? A: Request a formulary exception through your oncologist. Provide clinical documentation showing medical necessity and why formulary alternatives are inappropriate. Most California Blue Shield plans have exception processes for oncology drugs.

Q: Can I request an expedited appeal if treatment is urgent? A: Yes. California law requires expedited appeals when delays could seriously jeopardize health. Your oncologist must certify the urgency. Expedited internal appeals are decided within 72 hours.

Q: Does step therapy apply if I've tried other cancer drugs outside California? A: Prior therapy from any location counts toward step therapy requirements. Ensure your new California oncologist documents all previous treatments, including dates and outcomes, in your medical records.

Q: What's the difference between Cabometyx and Cometriq? A: These are different formulations of cabozantinib with distinct FDA approvals. Cabometyx (tablets) treats RCC, HCC, and thyroid cancer. Cometriq (capsules) is only for medullary thyroid carcinoma. They cannot be substituted.

Q: How much will Cabometyx cost with Blue Shield coverage? A: Costs vary by plan design. Specialty tier drugs typically require 25-40% coinsurance after deductible. Check with Blue Shield member services for your specific copay. Manufacturer copay assistance may be available.

Q: What if my specialty pharmacy can't get prior authorization approved? A: Work with your oncologist's office to submit the PA directly. Some specialty pharmacies have limited clinical documentation capabilities. Your cancer center typically has dedicated staff for complex PA submissions.

Q: Can I appeal to California state regulators if Blue Shield denies my IMR? A: IMR decisions are final and binding. However, if Blue Shield fails to comply with an IMR approval, you can file a complaint with DMHC. The state can impose penalties and order immediate compliance.

When Treatment Access Matters Most

Getting Cabometyx covered shouldn't delay your cancer treatment. Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical documentation to craft targeted, evidence-backed responses. Their platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements and appeal processes, significantly improving approval rates for critical oncology medications.

If you're facing repeated denials or complex coverage challenges, working with specialists who understand both the clinical and administrative requirements can make the difference between delayed care and timely treatment access.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by specific Blue Cross Blue Shield plan and individual circumstances. Always consult with your healthcare provider and insurance company for personalized guidance. For assistance with appeals or coverage disputes in California, contact the Department of Managed Health Care at 888-466-2219.

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