By Counterforce Health Team in Cabometyx (cabozantinib) —

How to Get Cabometyx (Cabozantinib) Covered by Blue Cross Blue Shield in North Carolina: Coding, Appeals, and Success Strategies

Quick Answer: Blue Cross Blue Shield of North Carolina requires prior authorization for Cabometyx (cabozantinib) across all plan types as of 2024. Your fastest path to approval: have your oncologist submit a PA request with proper ICD-10 codes (C64 for kidney cancer, C22.0 for liver cancer, C73 for thyroid cancer), documentation of failed prior therapies, and clear medical necessity. If denied, you have 60 days to appeal internally, then can escalate to North Carolina's Smart NC external review program. Start today by calling the provider services number on your Blue Cross NC card to confirm current PA requirements.

Table of Contents

Coding Basics: Medical vs. Pharmacy Benefit Paths

Understanding how Cabometyx gets billed determines your path to coverage with Blue Cross Blue Shield of North Carolina. The oral tablets (which represent the vast majority of Cabometyx prescriptions) typically fall under the pharmacy benefit, while any injectable formulations would be billed through the medical benefit.

Pharmacy Benefit Path (Most Common)

  • What gets billed: NDC codes for specific tablet strengths
  • Where it's processed: Through Blue Cross NC's pharmacy benefit manager
  • Prior authorization: Required across all Blue Cross NC plan types as of July 2024
  • Patient responsibility: Copay or coinsurance based on formulary tier

Medical Benefit Path (Injectable Only)

  • What gets billed: HCPCS J-code J9179 for cabozantinib injection
  • Where it's processed: Through medical claims with oncology visit
  • Additional codes needed: CPT codes for administration, appropriate diagnosis codes
  • Patient responsibility: Medical deductible and coinsurance apply
Note: Cabometyx tablets cannot be interchanged with cabozantinib capsules—they're different formulations with different dosing. Always verify you're prescribing and billing for the correct product.

ICD-10 Mapping for Cabometyx Coverage

Proper diagnosis coding is critical for Cabometyx approval. Blue Cross NC's medical necessity determination hinges on matching your diagnosis to FDA-approved indications.

Cancer Type ICD-10 Code Cabometyx Indication Documentation Keywords
Renal Cell Carcinoma C64 Advanced RCC after VEGF therapy or first-line intermediate/poor risk "Advanced," "metastatic," "post-sunitinib," "intermediate risk," "poor risk"
Hepatocellular Carcinoma C22.0 HCC after sorafenib treatment "Post-sorafenib," "progressive disease," "intolerant to sorafenib"
Differentiated Thyroid Cancer C73 RAI-refractory DTC after prior systemic therapy "RAI-refractory," "radioactive iodine resistant," "progressive," "locally advanced"

Documentation That Supports Medical Necessity

Your oncologist's notes should include specific language that aligns with FDA labeling:

  • Disease stage and progression: "Metastatic," "unresectable," "progressive disease"
  • Prior therapy failures: Names of specific drugs tried, dates, reasons for discontinuation
  • Performance status: ECOG or Karnofsky scores when available
  • Imaging evidence: RECIST criteria, progression dates, measurable disease

Product Coding: HCPCS, J-Codes, and NDC Numbers

NDC Codes for Cabometyx Tablets

  • 20 mg tablets: 57962-0304-30 (30-count bottle)
  • 40 mg tablets: 57962-0305-30 (30-count bottle)
  • 60 mg tablets: 57962-0306-30 (30-count bottle)

HCPCS J-Code (Injectable Only)

  • J9179: "Injection, cabozantinib, 1 mg"
  • Usage: Only for injectable cabozantinib in medical settings
  • Modifiers: Add JW for drug wastage, JZ for no waste

Units and Quantity Calculations

For oral tablets, quantity limits typically align with FDA-approved dosing:

  • Standard dosing: 60 mg daily = 30 tablets per 30 days
  • Reduced dosing: 40 mg or 20 mg daily for toxicity management
  • Combination therapy: May require different dosing per protocol
Tip: Blue Cross NC may require quantity limit exceptions for doses outside standard protocols. Include clinical rationale for non-standard dosing in your PA request.

Clean Prior Authorization Request Anatomy

A successful Cabometyx PA request to Blue Cross NC should include these elements in order:

1. Patient Demographics and Insurance Information

  • Full name, DOB, member ID
  • Group number and plan type
  • Prescribing provider NPI and contact information

2. Clinical Information

  • Primary diagnosis: ICD-10 code with clear description
  • Disease stage: TNM staging, AJCC stage, or equivalent
  • Performance status: ECOG 0-2 preferred for most indications
  • Relevant lab values: Liver function, kidney function, CBC

3. Treatment History

  • Prior therapies: Drug names, dates, duration, reason for discontinuation
  • Response to treatment: Best response, progression-free survival
  • Contraindications: Why first-line or preferred agents aren't suitable

4. Proposed Treatment Plan

  • Cabometyx dosing: Starting dose, frequency, duration
  • Monitoring plan: Lab schedules, imaging intervals
  • Combination therapy: If applicable, include partner drug details

5. Supporting Literature

  • FDA labeling: Reference specific indication sections
  • Clinical guidelines: NCCN, ASCO, or other society recommendations
  • Published studies: Key efficacy data for your patient's indication

Frequent Coding and Billing Pitfalls

Wrong Formulation Coding

Problem: Billing for cabozantinib capsules instead of Cabometyx tablets Solution: Always use NDC codes starting with 57962 for Cabometyx; capsule NDCs are different

Mismatched Diagnosis and Indication

Problem: Using C78.00 (secondary malignant neoplasm) instead of primary cancer code Solution: Bill primary cancer diagnosis (C64, C22.0, C73) even for metastatic disease

Missing Prior Authorization

Problem: Dispensing before PA approval, resulting in claim denial Solution: Verify PA status in Blue Cross NC provider portal before dispensing

Incorrect Quantity Calculations

Problem: Requesting 90-day supplies when plan limits to 30 days Solution: Check Blue Cross NC formulary for quantity limits; request exceptions separately

Unit Conversion Errors (Injectable)

Problem: Billing incorrect units for J9179 when converting from mg to billing units Solution: J9179 = 1 mg cabozantinib; verify total dose and calculate units accordingly

Verification with Blue Cross NC Resources

Before submitting any Cabometyx request, verify current requirements through official Blue Cross NC channels:

Provider Portal Checks

  1. Log into Blue Cross NC provider portal (verify current link on their main provider page)
  2. Check PA requirements: Search "Cabometyx" or "cabozantinib" in PA lookup tool
  3. Verify formulary status: Confirm tier placement and any restrictions
  4. Review member eligibility: Ensure coverage is active and plan type

Phone Verification

  • Provider services: Call the number on your provider ID card
  • Questions to ask: PA requirements, formulary tier, quantity limits, appeal procedures
  • Document the call: Representative name, reference number, date

Form Downloads

  • PA request forms: Download current version from provider portal
  • Appeal forms: Locate internal appeal and external review forms
  • Submission instructions: Confirm fax numbers, portal submission process

Appeals Process for North Carolina

When Blue Cross NC denies your Cabometyx request, North Carolina offers robust appeal rights through multiple levels.

Internal Appeals (Blue Cross NC)

First Level Appeal

  • Timeline: File within 60 days of denial notice
  • How to submit: Written appeal via mail, fax, or provider portal
  • Required documents: Original PA request, denial letter, additional clinical support
  • Decision timeline: 30 days for standard, 72 hours for expedited

Second Level Appeal

  • When available: After first-level denial
  • Process: Similar to first level with different reviewers
  • Timeline: Same as first level

External Review (Smart NC)

If internal appeals fail, North Carolina's Smart NC program provides independent review:

  • Eligibility: Must exhaust Blue Cross NC internal appeals first
  • Timeline: Apply within 4 months of final internal denial
  • Cost: Free to patients
  • Process: Independent medical experts review your case
  • Decision timeline: 45 days standard, 72 hours expedited
  • Success rate: Approximately 40-50% of external reviews overturn insurer denials

How to Apply for External Review:

  1. Contact Smart NC at 1-855-408-1212
  2. Complete external review request form
  3. Submit medical records and denial letters
  4. Smart NC assigns Independent Review Organization (IRO)
  5. IRO issues binding decision
From our advocates: We've seen Cabometyx denials successfully overturned when the appeal included detailed progression imaging, clear documentation of sorafenib failure (for HCC), and specific citations from NCCN guidelines. The key is showing that your patient's case aligns exactly with FDA-approved indications while addressing the specific denial reason.

When to Request Expedited Review

Request expedited appeals when:

  • Delay would seriously jeopardize health or ability to regain function
  • Cancer is rapidly progressing
  • Patient is experiencing severe symptoms
  • Current therapy is failing and immediate switch is medically necessary

Quick Pre-Submission Audit Checklist

Before submitting your Cabometyx PA or appeal, verify:

Clinical Documentation

  • Correct ICD-10 code matches FDA indication
  • Clear disease staging and progression evidence
  • Documented prior therapy failures with dates
  • Performance status documented
  • Contraindications to alternatives addressed

Coding Accuracy

  • Correct NDC for tablet strength prescribed
  • Quantity aligns with FDA dosing and plan limits
  • J-code J9179 used only for injectable (if applicable)
  • Units calculated correctly for billing

Administrative Requirements

  • Current PA form used
  • All required fields completed
  • Provider NPI and contact information included
  • Patient demographics match insurance card exactly
  • Supporting documents attached

Submission Process

  • Correct fax number or portal confirmed
  • Submission method matches Blue Cross NC requirements
  • Copies retained for records
  • Follow-up plan established for decision timeline

FAQ

How long does Blue Cross NC prior authorization take for Cabometyx? Standard PA decisions are typically made within 72 hours for pharmacy benefit requests. Expedited requests for urgent cases can be processed within 24 hours.

What if Cabometyx is non-formulary on my Blue Cross NC plan? You can request a formulary exception by demonstrating medical necessity and why formulary alternatives aren't appropriate. Include documentation of failed preferred therapies or contraindications.

Can I request an expedited appeal if my Cabometyx is denied? Yes, if the delay would seriously jeopardize your health. Your oncologist must provide clinical justification for the urgency, such as rapidly progressing cancer or failure of current therapy.

Does step therapy apply to Cabometyx in North Carolina? Blue Cross NC may require trying preferred agents first, but step therapy can be overridden with documentation of contraindications, prior failures, or medical necessity for immediate Cabometyx use.

What happens if my external review through Smart NC is denied? The IRO decision is binding on Blue Cross NC. If approved, they must provide coverage within 3 business days. If denied, you've exhausted administrative appeals, though you may have other legal rights to pursue.

How do I find my specific Blue Cross NC plan's formulary? Log into your member portal or call the member services number on your insurance card. Each Blue Cross NC plan type may have different formulary tiers and restrictions.

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals through evidence-backed, targeted rebuttals. The platform analyzes denial letters and plan policies to craft point-by-point appeals that align with each payer's specific requirements, pulling the right clinical citations and operational details that payers expect to see.

For complex cases like Cabometyx appeals, having the right evidence and procedural knowledge can make the difference between approval and denial. Counterforce Health streamlines this process by ensuring appeals meet Blue Cross NC's specific criteria while tracking deadlines and required documentation.

Sources & Further Reading

This guide provides educational information about insurance coverage and appeals processes. It is not medical advice. Always consult with your healthcare provider about treatment decisions and work with your insurance company directly for coverage determinations. For personalized help with North Carolina insurance appeals, contact Smart NC at 1-855-408-1212.

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