By Counterforce Health Team in Opdivo (nivolumab) —

How to Get Opdivo (nivolumab) Covered by Humana Medicare in Illinois: Prior Authorization, Appeals & Coding Guide

Answer Box: Getting Opdivo Covered by Humana in Illinois

Opdivo (nivolumab) requires prior authorization from Humana Medicare Advantage plans in Illinois. Your fastest path to approval: 1) Have your oncologist submit a prior authorization request with complete clinical documentation including diagnosis codes, treatment history, and medical necessity justification; 2) Use correct HCPCS code J9299 and ensure proper ICD-10 coding for your specific cancer type; 3) If denied, file an internal appeal within 65 days, then pursue Illinois external review within 4 months if needed. Start with Humana's prior authorization portal or fax 1-877-486-2621.

Table of Contents

  1. Coverage Basics: Medical vs. Pharmacy Benefit
  2. ICD-10 Coding for Opdivo Indications
  3. HCPCS/J-Code and NDC Requirements
  4. Prior Authorization: Building a Clean Request
  5. Common Coding Pitfalls to Avoid
  6. Humana Verification Resources
  7. Appeals Process in Illinois
  8. Pre-Submission Audit Checklist
  9. FAQ

Coverage Basics: Medical vs. Pharmacy Benefit

Opdivo (nivolumab) is covered under Medicare Part B as a physician-administered drug, not through Part D prescription drug coverage. This means it falls under your Humana Medicare Advantage medical benefit, typically with 20% coinsurance after you meet your deductible.

Coverage at a Glance

Requirement Details Where to Find It Source
Prior Authorization Required for all Humana Medicare plans Humana PA Lists Humana Provider Portal
HCPCS Code J9299 (1 mg = 1 billing unit) Medicare billing guidelines CMS HCPCS Database
Administration Site Approved infusion centers only Plan documents Humana Medical Policy
Step Therapy May apply - check preferred alternatives 2025 Step Therapy List Humana Provider Resources

ICD-10 Coding for Opdivo Indications

Proper ICD-10 coding is critical for Opdivo approval. Your diagnosis must align with FDA-approved indications to meet medical necessity criteria.

Melanoma

  • C43 - Malignant melanoma of skin (primary code family)
  • C43.9 - Malignant melanoma of skin, unspecified (most common)
  • Z85.820 - Personal history of malignant melanoma (for surveillance/recurrence)

Non-Small Cell Lung Cancer (NSCLC)

  • C78.0 - Secondary malignant neoplasm of lung
  • Use specific lung anatomy codes (C34.1, C34.2) for primary tumors
  • Include staging codes when applicable

Renal Cell Carcinoma

  • C64.1 - Malignant neoplasm of right kidney
  • C64.2 - Malignant neoplasm of left kidney
  • C64.9 - Malignant neoplasm of kidney, unspecified

Head and Neck Cancers

  • C07 - Malignant neoplasm of parotid gland
  • C08.0 - Malignant neoplasm of submandibular gland
  • C76 - Other head and neck sites
Documentation Tip: Include metastatic site codes (C77-C79) when applicable, as advanced/metastatic disease often supports medical necessity for immunotherapy.

HCPCS/J-Code and NDC Requirements

Essential Coding Information

  • HCPCS Code: J9299 (injection, nivolumab, 1 mg)
  • Billing Units: 1 mg = 1 unit (e.g., 240 mg dose = 240 units)
  • Common NDCs: 00003-3734-13, 00003-3756-14, 00003-3772-11

Dosing Calculations

Opdivo dosing varies by indication:

  • Weight-based: 3 mg/kg every 2 weeks
  • Flat dosing: 240 mg every 2 weeks or 480 mg every 4 weeks

Example Calculation:

  • Patient weight: 70 kg
  • Dose: 3 mg/kg × 70 kg = 210 mg
  • Billing units: 210 units of J9299

New Subcutaneous Option

The FDA approved Opdivo Qvantig (subcutaneous nivolumab) in December 2024, coded as J9289. This may offer coverage advantages for some patients due to reduced administration costs.

Prior Authorization: Building a Clean Request

Step-by-Step Submission Process

  1. Gather Required Documentation (Patient/Clinic)
    • Insurance card and member ID
    • Complete pathology reports
    • Imaging studies showing disease extent
    • Prior treatment records and outcomes
    • Current performance status assessment
  2. Complete Clinical Justification (Oncologist)
    • FDA-approved indication alignment
    • Prior therapy failures or contraindications
    • NCCN guideline references
    • Treatment goals and monitoring plan
  3. Submit via Preferred Channel (Clinic Staff)
    • Humana Provider Portal (recommended)
    • Fax: 1-877-486-2621
    • Standard processing: 72 hours
    • Expedited: 24 hours (for urgent cases)

Medical Necessity Letter Checklist

Your oncologist's letter should include:

  • ✅ Specific diagnosis with ICD-10 codes
  • ✅ Disease staging and biomarker status
  • ✅ Prior treatments tried and outcomes
  • ✅ Why alternatives aren't appropriate
  • ✅ Opdivo dosing plan and monitoring schedule
  • ✅ References to FDA labeling and NCCN guidelines

Counterforce Health specializes in helping patients and clinicians build comprehensive prior authorization requests that align with payer requirements. Their platform can help identify the specific denial reasons and craft targeted appeals with the right clinical evidence and procedural documentation.

Common Coding Pitfalls to Avoid

Unit Conversion Errors

  • Wrong: Billing vial quantity instead of mg amount
  • Right: Calculate total mg administered and bill accordingly
  • Example: 240 mg vial used completely = 240 units of J9299

Mismatched Diagnosis Codes

  • Wrong: Using generic cancer codes (C80.1)
  • Right: Specific anatomical site codes matching FDA indications
  • Impact: Generic codes often trigger automatic denials

Missing Documentation Dates

  • Always include:
    • Date of diagnosis
    • Prior treatment start/stop dates
    • Progression documentation dates
    • Current treatment plan start date

Incorrect NDC Usage

  • Use manufacturer-specific NDCs from Bristol Myers Squibb
  • Verify NDC matches the actual product administered
  • Update codes annually as manufacturers may change numbers

Humana Verification Resources

Before submitting your prior authorization, verify current requirements:

Online Resources

Phone Verification

  • Provider Services: 1-800-457-4708
  • Member Services: Number on member ID card
  • Prior Authorization Status: Available through provider portal

Cross-Check Process

  1. Confirm Opdivo is on your specific plan's formulary
  2. Review any quantity limits or site-of-care restrictions
  3. Check for step therapy requirements
  4. Verify current PA form version and submission method

Appeals Process in Illinois

If your initial prior authorization is denied, Illinois provides strong appeal rights with specific timelines.

Internal Appeals (Level 1)

  • Deadline: 65 days from denial notice
  • Timeline: Standard decisions within 30 days, expedited within 72 hours
  • Submit to: Humana appeals department (address on denial letter)
  • Required: Additional clinical evidence addressing denial reasons

External Review (Level 2)

Illinois offers independent external review through the Illinois Department of Insurance:

  • Deadline: 4 months from final internal denial
  • Cost: Free to consumers
  • Timeline: Decision within 5 business days of IRO receiving materials
  • Scope: Medical necessity and experimental treatment determinations
Illinois Advantage: The state's external review process is faster than many states and includes expedited options (24-72 hours) for urgent cases.

When to Escalate

Contact Illinois Department of Insurance if:

  • Humana misses appeal deadlines
  • You need help understanding your rights
  • Phone: 877-527-9431 (Consumer Health Insurance Office)

For complex cases involving rare cancers or off-label use, Counterforce Health can help build evidence-based appeals that address specific payer concerns and regulatory requirements.

Pre-Submission Audit Checklist

Before submitting your Opdivo prior authorization:

Clinical Documentation:

  • Complete pathology report with specific cancer type
  • Staging information (TNM staging, imaging reports)
  • Biomarker testing results (PD-L1, MSI, TMB as applicable)
  • Prior treatment history with dates and outcomes
  • Current performance status (ECOG/Karnofsky)

Coding Accuracy:

  • Correct ICD-10 codes for primary diagnosis
  • HCPCS J9299 with accurate unit calculation
  • Proper NDC for Bristol Myers Squibb product
  • Administration site verification

Administrative Requirements:

  • Current Humana PA form (verify version date)
  • Provider NPI and facility information
  • Member ID and plan details
  • Prescriber attestation signature

Medical Necessity Support:

  • FDA indication alignment clearly stated
  • NCCN guideline references included
  • Alternative therapy considerations addressed
  • Treatment goals and monitoring plan outlined

FAQ

How long does Humana prior authorization take for Opdivo in Illinois? Standard processing is 72 hours, with expedited decisions available within 24 hours for urgent cases. Submit through the provider portal for fastest processing.

What if Opdivo isn't on my Humana formulary? You can request a formulary exception by demonstrating medical necessity. Include evidence that preferred alternatives aren't appropriate due to contraindications, prior failures, or clinical factors.

Does step therapy apply to Opdivo in Illinois Humana plans? Possibly. Check Humana's 2025 Step Therapy List for current requirements. You may need to try preferred immunotherapies first unless contraindicated.

Can I request an expedited appeal for Opdivo? Yes, if delays would seriously jeopardize your health. Expedited appeals receive decisions within 72 hours for internal appeals and 24-72 hours for Illinois external review.

What happens if I'm denied after external review? External review decisions are binding on your insurer. If approved, Humana must cover the treatment. If denied, you may have limited options beyond seeking alternative treatments or coverage sources.

How much will I pay for Opdivo with Humana Medicare? Typically 20% coinsurance after meeting your annual deductible. For a $7,943 vial, your cost would be approximately $1,589 per dose, though manufacturer copay assistance may be available.

Sources & Further Reading

Medical Disclaimer: This article provides general information about insurance coverage and is not medical advice. Always consult with your healthcare provider about treatment decisions and work with your insurance company directly for coverage determinations. Coverage policies and requirements change frequently - verify current information with official sources.

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by providing evidence-backed, payer-specific strategies. The platform identifies denial reasons and creates targeted rebuttals aligned with each plan's requirements, helping streamline the approval process for complex specialty medications like Opdivo.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.