By Counterforce Health Team in Poteligeo (mogamulizumab-kpkc) —

How to Get Poteligeo (mogamulizumab-kpkc) Covered by Humana in Virginia: Complete Coding, Prior Authorization, and Appeals Guide

Quick Answer: Getting Poteligeo Covered by Humana in Virginia

Poteligeo (mogamulizumab-kpkc) is covered under Medicare Part B medical benefit by Humana, not Part D pharmacy. Key steps: 1) Ensure proper ICD-10 coding (C84.0x for mycosis fungoides, C84.1x for Sézary syndrome), 2) Submit prior authorization with documented prior systemic therapy failures, and 3) Use HCPCS code J9204 for billing. If denied, Virginia residents have 120 days to file external review with the State Corporation Commission Bureau of Insurance using Form 216-A. Start today by verifying your Humana plan's specific PA requirements through their provider portal.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit
  2. ICD-10 Mapping for CTCL
  3. Product Coding: HCPCS J9204 and NDC
  4. Clean Prior Authorization Request
  5. Frequent Coding Pitfalls
  6. Verification with Humana
  7. Appeals Process in Virginia
  8. Quick Audit Checklist

Coding Basics: Medical vs. Pharmacy Benefit

Understanding how Humana classifies Poteligeo is crucial for successful coverage. Poteligeo (mogamulizumab-kpkc) is covered under Medicare Part B as a medical benefit, not Part D pharmacy benefit. This means:

  • Administration: Must be given by a healthcare provider in a medical setting (clinic, infusion center, hospital outpatient)
  • Billing pathway: Uses medical benefit with 20% coinsurance after Part B deductible ($240 in 2026)
  • No formulary restrictions: Not subject to Part D formulary tiers or pharmacy networks
  • Prior authorization: May still be required under medical benefit policies
Note: This classification affects your out-of-pocket costs and where you receive treatment. Verify with your provider that they can administer infusions and bill under Part B.

ICD-10 Mapping for CTCL

Accurate diagnosis coding is essential for Poteligeo approval. The FDA indication requires relapsed or refractory mycosis fungoides or Sézary syndrome after at least one prior systemic therapy.

Primary ICD-10 Codes

Diagnosis ICD-10 Code Documentation Requirements
Mycosis fungoides, unspecified site C84.00 Pathology showing cerebriform T-cells, CD4+
Mycosis fungoides, lymph nodes of head/neck C84.01 Imaging confirmation of nodal involvement
Mycosis fungoides, intrathoracic lymph nodes C84.02 CT chest showing affected nodes
Mycosis fungoides, intra-abdominal lymph nodes C84.03 CT abdomen/pelvis documentation
Sézary syndrome C84.1x Flow cytometry showing Sézary cells >1000/μL

Supporting Documentation Words

When documenting for PA requests, include these clinical terms that support proper coding:

  • "Relapsed cutaneous T-cell lymphoma"
  • "Progressive mycosis fungoides despite prior systemic therapy"
  • "Cerebriform T-lymphocytes on skin biopsy"
  • "CD4+ malignant T-cell clone"
  • "ISCL/EORTC staging"

Product Coding: HCPCS J9204 and NDC

HCPCS Code J9204

J9204: Injection, mogamulizumab-kpkc, 1 mg (effective October 1, 2019)

  • Billing unit: 1 mg = 1 unit
  • NDC: 42747-0761-01 (20 mg/5 mL single-dose vial)
  • Revenue code: 0636 for hospital outpatient claims

Dosing and Units Calculation

Standard Poteligeo dosing: 1 mg/kg IV

  • Cycle 1: Days 1, 8, 15, 22
  • Subsequent cycles: Days 1, 15

Example calculation for 70 kg patient:

  • Dose per infusion: 70 mg
  • Bill as: 70 units of J9204
  • Important: Bill exact mg administered, not rounded to vials

Required Modifiers

Modifier When to Use Purpose
UD 340B eligible hospitals Indicates 340B drug pricing
JW Drug wastage Documents discarded amount
11-digit NDC All claims Links to specific product

Clean Prior Authorization Request

A complete PA request significantly improves approval chances. Based on typical payer patterns, include:

Clinical Documentation Checklist

  • Patient demographics: Full name, DOB, member ID
  • Pathology report: Confirming CTCL subtype with immunohistochemistry
  • Staging information: ISCL/EORTC staging if available
  • Prior systemic therapies: Drug names, dates, duration, outcomes, reasons for discontinuation
  • Treatment plan: Dosing schedule (1 mg/kg), infusion site, monitoring plan
  • Prescriber credentials: NPI number, specialty (oncology/hematology/dermatology)

Medical Necessity Letter Template

Your oncologist should include:

  1. Clinical presentation: Stage, symptoms, disease progression
  2. Prior treatment failures: Specific therapies tried and why they failed
  3. Rationale for Poteligeo: FDA indication, NCCN guidelines support
  4. Monitoring plan: How side effects will be managed
  5. Treatment goals: Disease control, symptom improvement
Clinician Corner: Reference NCCN Guidelines for T-Cell Lymphomas, which list mogamulizumab as Category 1 recommendation for relapsed/refractory mycosis fungoides and Sézary syndrome.

Frequent Coding Pitfalls

Common Mistakes That Cause Denials

  1. Wrong benefit category: Submitting to Part D instead of Part B
  2. Incorrect units: Rounding to vials instead of exact mg
  3. Missing NDC: 11-digit NDC is required for J-code billing
  4. Inadequate prior therapy documentation: Vague statements about "failed treatments"
  5. Wrong diagnosis codes: Using general lymphoma codes instead of specific CTCL codes

Documentation Gaps to Avoid

  • Missing pathology: Approval requires confirmed CTCL diagnosis
  • Insufficient prior therapy details: List specific drugs, not just "chemotherapy"
  • No staging information: Include disease extent when available
  • Unclear treatment plan: Specify dosing, schedule, and duration

Verification with Humana

Before submitting your PA request:

Check Coverage Status

  • Use Humana's provider portal to verify current PA requirements
  • Call Humana Provider Services for medication-specific criteria
  • Confirm patient's Part B coverage is active

Required Forms

  • Download current PA forms from Humana's provider portal
  • Verify submission method (online portal, fax, or mail)
  • Check if expedited review is available for urgent cases

Appeals Process in Virginia

If Humana denies your Poteligeo request, Virginia provides robust appeal rights through the State Corporation Commission Bureau of Insurance.

Internal Appeals with Humana

Timeline: 60 days for standard Medicare appeals, 72 hours for expedited

  • File through Humana's member portal or by phone
  • Include additional clinical documentation
  • Request peer-to-peer review with oncologist

Virginia External Review Process

After exhausting Humana's internal appeals:

  1. Submit Form 216-A to Virginia Bureau of Insurance within 120 days of final denial
  2. Required documents: Denial letter, medical records, treatment plan
  3. Timeline: 45 days for standard review, 72 hours for expedited urgent cases
  4. Cost: Free to patients
  5. Decision: Binding on Humana if approved

Contact: Virginia Bureau of Insurance, P.O. Box 1157, Richmond, VA 23218 | Phone: (804) 371-9631

When to Request Expedited Review

  • Disease progression requiring immediate treatment
  • Risk of permanent disability or death
  • Doctor certifies that delay would jeopardize health

Counterforce Health specializes in transforming insurance denials into successful appeals by analyzing payer policies and crafting evidence-backed rebuttals. Their platform helps patients and clinicians navigate complex prior authorization requirements and appeal processes more effectively.

Quick Audit Checklist

Before submitting any Poteligeo request to Humana:

Clinical Documentation

  • Confirmed CTCL diagnosis with pathology
  • Documented prior systemic therapy failures
  • Current staging and disease status
  • Treatment plan with dosing schedule

Coding Accuracy

  • Correct ICD-10 (C84.0x or C84.1x)
  • HCPCS J9204 with exact mg units
  • 11-digit NDC included
  • Appropriate modifiers applied

Administrative Requirements

  • Current PA form completed
  • Prescriber NPI and specialty verified
  • Patient eligibility confirmed
  • Submission method verified

Frequently Asked Questions

How long does Humana prior authorization take for Poteligeo in Virginia? Standard PA decisions typically take 14-30 days. Expedited reviews for urgent cases can be completed within 72 hours if medical necessity is demonstrated.

What if Poteligeo is not on Humana's formulary? Since Poteligeo is covered under Part B medical benefit, formulary restrictions don't apply. However, medical necessity must still be established through the PA process.

Can I appeal if my oncologist is out-of-network with Humana? Yes, but you may need to request an exception for specialty care if no in-network CTCL specialists are available in your area.

Does step therapy apply to Poteligeo in Virginia? This varies by plan. Many require documentation of prior systemic therapy failures, which aligns with FDA labeling requirements.

What happens if Virginia external review denies my appeal? The decision is binding, but you retain rights to pursue legal action separately or explore other coverage options like manufacturer assistance programs.

Cost-Saving Resources

  • Kyowa Kirin Patient Support: Offers copay assistance and financial counseling
  • Virginia Medicaid: May provide secondary coverage for eligible patients
  • Cancer support organizations: Local foundations may offer grant assistance

For patients navigating complex coverage decisions, Counterforce Health provides specialized support in turning denials into approvals through targeted, evidence-based appeals that align with specific payer requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions vary by individual circumstances and plan details. Always consult with your healthcare provider and insurance company for personalized guidance. For assistance with insurance appeals in Virginia, contact the State Corporation Commission Bureau of Insurance.

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