By Counterforce Health Team in Cresemba (isavuconazole) —

How to Get Cresemba (Isavuconazole) Covered by Blue Cross Blue Shield in New York: Complete Coding, Prior Authorization & Appeals Guide

Answer Box: Getting Cresemba Covered by Blue Cross Blue Shield in New York

Blue Cross Blue Shield (BCBS) in New York requires prior authorization for Cresemba (isavuconazole) with specific coding and documentation. Use ICD-10 code B44.0 for invasive aspergillosis, HCPCS J1833 for IV billing, and NDC 0469-0420-01 for the IV formulation. Submit PA requests through Availity Essentials portal with complete diagnostic evidence. If denied, you have 180 days for internal appeals and 4 months for New York State external appeals through DFS. First step: gather your diagnosis confirmation, prior treatment records, and insurance card details.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit Paths
  2. ICD-10 Mapping for Invasive Fungal Infections
  3. Product Coding: HCPCS, J-Codes, and NDCs
  4. Clean Request Anatomy: Building Your PA Submission
  5. Frequent Coding Pitfalls to Avoid
  6. Verification with BCBS Resources
  7. Quick Audit Checklist
  8. Appeals Playbook for New York
  9. Common Denial Reasons & Solutions
  10. FAQ

Coding Basics: Medical vs. Pharmacy Benefit Paths

Understanding whether Cresemba flows through your medical benefit or pharmacy benefit determines which codes you'll use and how to structure your claim.

Medical Benefit (Most Common)

  • When: IV Cresemba administered in hospitals, infusion centers, or clinics
  • Primary Code: HCPCS J1833 (Injection, isavuconazonium, 1 mg)
  • Units: Bill per milligram administered (372 mg dose = 372 units)
  • Administration: CPT 96365 (initial IV infusion up to 1 hour)
  • Revenue Codes: 0250 (Pharmacy, general) or 0260 (IV therapy)

Pharmacy Benefit (Oral Forms)

  • When: Oral capsules dispensed through retail or specialty pharmacy
  • Primary Identifier: NDC codes for product verification
  • Billing: Standard pharmacy claim with days supply and quantity
Tip: Most insurance approvals start with IV therapy during the loading phase, then transition to oral maintenance. Plan your coding strategy for both phases.

ICD-10 Mapping for Invasive Fungal Infections

Precise diagnosis coding is critical for Cresemba approval. Use the most specific code available based on your diagnostic evidence.

Primary Diagnosis Codes

Condition ICD-10 Code Documentation Required
Invasive pulmonary aspergillosis B44.0 CT/MRI imaging, culture, or tissue biopsy
Other pulmonary aspergillosis B44.1 Clinical/radiologic evidence
Disseminated aspergillosis B44.7 Multi-organ involvement documented
Pulmonary mucormycosis B46.0 Histopathology or culture confirmation
Rhinocerebral mucormycosis B46.1 ENT/neurology consultation notes

Supporting Documentation Language

Your medical records should include specific terminology that supports your chosen ICD-10 code:

  • "Confirmed invasive aspergillosis" or "probable IA per EORTC criteria"
  • "Positive galactomannan" or "characteristic halo sign on CT"
  • "Tissue invasion documented on biopsy"
  • "Immunocompromised host with compatible clinical syndrome"
Note: Avoid unspecified codes like B49 (Unspecified mycosis) unless truly no specific diagnosis can be established.

Product Coding: HCPCS, J-Codes, and NDCs

HCPCS J-Code Details

  • J1833: Injection, isavuconazonium, 1 mg
  • Billing Unit: Always per 1 mg
  • Standard Dose: 372 mg = 372 billing units
  • Loading Phase: 6 doses over 48 hours = 2,232 total units
  • Maintenance: 372 units daily

NDC Numbers by Formulation

Formulation NDC Package Size Use Case
IV single-dose vial 0469-0420-01 372 mg/vial Hospital/infusion center
Oral capsules 186 mg 0469-0520-02 14-count carton Outpatient maintenance
Oral capsules 74.5 mg 0469-2860-35 35-count carton Pediatric/weight-based dosing

Units Math Examples

  • Day 1 loading: 372 mg × 2 doses = 744 units (J1833)
  • Maintenance week: 372 mg × 7 days = 2,604 units
  • 30-day supply oral: 30 capsules × 186 mg = report as quantity 30

Clean Request Anatomy: Building Your PA Submission

A complete prior authorization request includes these essential elements:

Patient Information Section

Patient: [Name], DOB: [Date]
Member ID: [BCBS ID number]
Diagnosis: Invasive pulmonary aspergillosis (B44.0)
Prescriber: [MD name], NPI: [Number]

Clinical Justification Block

INDICATION: Confirmed invasive aspergillosis in immunocompromised host
DIAGNOSTIC EVIDENCE: 
- CT chest showing pulmonary nodules with halo sign (date)
- Positive serum galactomannan 2.1 (normal <0.5)
- BAL culture pending, started empirically per ID consultation

DOSING REQUEST:
- Loading: 372 mg IV q8h × 6 doses (J1833, 2,232 units total)
- Maintenance: 372 mg IV daily × 14 days, then PO (J1833, 5,208 units)

MEDICAL NECESSITY: Patient neutropenic s/p stem cell transplant, 
high mortality risk without immediate antifungal therapy

Supporting Documents Checklist

  • Completed BCBS NY PA form
  • Imaging reports (CT, MRI)
  • Laboratory results (galactomannan, beta-D-glucan)
  • Infectious disease consultation note
  • Hospital discharge summary (if applicable)

Frequent Coding Pitfalls to Avoid

Unit Conversion Errors

  • Wrong: Billing J1833 as "per vial" (372 units becomes 1 unit)
  • Right: Bill per mg administered (372 mg = 372 units)

Mismatched NDC/HCPCS

  • Wrong: Using oral NDC (0469-0520-02) with J1833 code
  • Right: IV NDC (0469-0420-01) with J1833 for injection claims

Missing Date Alignment

  • Wrong: Service date before PA approval date
  • Right: Ensure all claim dates fall within authorized period

Incomplete Diagnosis Coding

  • Wrong: Using only B49 (unspecified mycosis)
  • Right: Most specific code supported by documentation (B44.0, B46.0)

Verification with BCBS Resources

Before submitting your request, cross-check your codes and requirements:

Online Verification Tools

  1. Availity Essentials: Check member eligibility and PA status
  2. BCBS Provider Portal: Download current PA forms and drug policies
  3. Formulary Lookup: Confirm Cresemba tier status and restrictions

Direct Verification Steps

  1. Call BCBS provider services (number on member card)
  2. Verify member's specific plan covers J1833
  3. Confirm current PA requirements haven't changed
  4. Check if infectious disease consultation is mandatory
Tip: Screenshot or print verification confirmations with date/time stamps for your records.

Quick Audit Checklist

Use this pre-submission checklist to catch common errors:

Patient & Coverage

  • Member ID matches insurance card exactly
  • Coverage active on service dates
  • Prior authorization submitted before treatment

Coding Accuracy

  • ICD-10 code matches documented diagnosis
  • HCPCS J1833 used for IV administration
  • Correct NDC for actual product used
  • Units calculated as mg administered

Clinical Documentation

  • Diagnosis confirmed with objective evidence
  • Medical necessity clearly stated
  • Prior treatments documented (if applicable)
  • Prescriber credentials and contact info included

Submission Details

  • All required forms completed
  • Supporting documents attached
  • Submitted via correct portal/fax
  • Confirmation receipt obtained

Appeals Playbook for New York

If your initial PA request is denied, New York offers robust appeal rights with specific timelines.

Internal Appeals (First Level)

  • Deadline: 180 days from denial notice
  • Timeline: BCBS must respond within 30 days (72 hours if expedited)
  • Submit via: BCBS member portal or written appeal
  • Include: Original denial letter, additional clinical evidence, provider letter

External Appeals (New York State DFS)

  • Eligibility: After completing internal appeal process
  • Deadline: 4 months from final adverse determination
  • Timeline: 30 days standard, 72 hours expedited (24 hours for urgent drug denials)
  • Fee: Maximum $25 (waived for financial hardship)
  • Submit: DFS External Appeal Portal

Expedited Appeal Criteria

Request expedited review when:

  • Delay could seriously jeopardize health
  • Patient has active invasive fungal infection
  • Currently hospitalized or in critical condition
  • Provider certifies medical urgency
Important: External appeal decisions are binding on BCBS. If overturned, they must cover treatment and refund your appeal fee.

For free help with appeals, contact Community Health Advocates at (888) 614-5400.

Common Denial Reasons & Solutions

Denial Reason Solution Strategy Key Documents
"Not medically necessary" Submit specialist consultation, clinical guidelines ID consult note, IDSA guidelines
"Experimental/investigational" Provide FDA approval documentation FDA label, peer-reviewed studies
"Step therapy required" Document voriconazole failure/contraindication Prior treatment records, allergy history
"Non-formulary drug" Request formulary exception with clinical rationale Medical necessity letter, alternative failures
"Quantity limits exceeded" Justify extended duration based on infection severity Culture results, treatment response monitoring

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes your denial letter and plan policy to draft point-by-point rebuttals aligned with your payer's specific requirements, potentially saving weeks of back-and-forth correspondence.

FAQ

Q: How long does BCBS prior authorization take for Cresemba in New York? A: Standard review takes 5-15 business days. Expedited requests for clinical urgency are reviewed within 72 hours.

Q: What if Cresemba is non-formulary on my BCBS plan? A: You can request a formulary exception by demonstrating medical necessity and failure of preferred alternatives. Include detailed clinical rationale from your prescriber.

Q: Can I start treatment while waiting for PA approval? A: For life-threatening infections, hospitals often start treatment and seek retroactive approval. Discuss with your care team and insurance coordinator.

Q: Does step therapy apply if I failed voriconazole outside New York? A: Yes, prior treatment failures from any location count toward step therapy requirements. Provide documentation from all previous providers.

Q: What's the success rate for Cresemba appeals in New York? A: With proper documentation and clinical justification, many denials are overturned. New York's external appeal process has historically favored patients with strong medical evidence.

Q: Can I get help with the appeal process? A: Yes, Community Health Advocates provides free assistance at (888) 614-5400. Counterforce Health also offers specialized appeal support for complex drug denials.

Q: What if my doctor isn't familiar with PA requirements? A: Share this guide with your prescriber. Many practices have dedicated prior authorization staff, or you can request a peer-to-peer review where your doctor speaks directly with the insurance medical director.

Q: Are there patient assistance programs for Cresemba? A: Astellas offers patient support programs. Contact their Patient Support Solutions at the number on their official website for eligibility information.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Coverage decisions depend on your specific insurance plan and clinical circumstances. Always consult with your healthcare provider and insurance plan for personalized guidance. For additional support with complex insurance appeals, consider consulting with healthcare coverage specialists like those at Counterforce Health.

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