By Counterforce Health Team in Sylvant (siltuximab) —

How to Get Sylvant (Siltuximab) Covered by Humana in Virginia: Coding, Appeals, and State Review Process

Answer Box: Getting Sylvant Covered by Humana in Virginia

Sylvant (siltuximab) requires prior authorization from Humana for idiopathic multicentric Castleman disease (iMCD). Use ICD-10 code D47.Z2 and HCPCS J-code J2860 (10 mg units). Submit PA requests through Humana's provider portal with HIV/HHV-8 negative test results and weight-based dosing (11 mg/kg every 3 weeks). If denied, you have 65 days to appeal internally, then 120 days to request Virginia State Corporation Commission external review. Start today: Gather your diagnosis confirmation, negative HIV/HHV-8 tests, and current weight documentation.

Table of Contents

Coding Basics: Medical vs. Pharmacy Benefit

Sylvant (siltuximab) is typically covered under the medical benefit rather than pharmacy benefit due to its intravenous administration in clinical settings. This physician-administered drug follows a "buy and bill" model where providers purchase the medication, administer it, and then bill insurance using specific medical codes.

Coverage Path:

  • Medical Benefit: Standard pathway using HCPCS J-codes
  • Pharmacy Benefit: Rarely used; check with Humana for specific plan coverage
Note: Always verify benefit coverage with Humana before administration, as some Medicare Advantage plans may have different pathways for specialty biologics.

ICD-10 Mapping and Documentation

Primary Diagnosis Code

ICD-10 Code D47.Z2 - "Castleman disease" is the appropriate code for idiopathic multicentric Castleman disease (iMCD). There's no separate code specifically for "idiopathic" multicentric Castleman disease.

Required Documentation for D47.Z2

Your medical record must clearly document:

  • Excisional lymph node biopsy showing characteristic Castleman histopathology
  • Multicentric lymphadenopathy confirmed by CT or PET-CT imaging
  • Laboratory evidence of systemic inflammation (elevated CRP, ESR, anemia, hypoalbuminemia)
  • Organ dysfunction attributable to iMCD
  • HIV serology: NEGATIVE (documented with date and test type)
  • HHV-8 testing: NEGATIVE (immunohistochemistry for LANA-1 or PCR)
Critical: Both HIV and HHV-8 must be documented as negative. If either is positive, the diagnosis becomes HIV/HHV-8-associated MCD, which is a different condition with different coding implications.

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

HCPCS J-Code

J2860 - Injection, siltuximab, 10 mg

  • Each billable unit = 10 mg
  • Calculate total units by dividing total dose by 10

NDC Numbers (2024)

  • 100 mg vial: NDC 57955-0100-01
  • 400 mg vial: NDC 57955-0400-01

Dosing Calculation

Standard dose: 11 mg/kg every 3 weeks

Example Calculation:

  • Patient weight: 70 kg
  • Total dose: 70 kg × 11 mg/kg = 770 mg
  • Billable units: 770 mg ÷ 10 = 77 units
  • Vials needed: 1 × 400 mg vial + 1 × 100 mg vial (with 330 mg discarded)
Tip: Always use the patient's most current weight in kilograms. Convert pounds to kg using: weight in lbs ÷ 2.20462 = kg.

Clean Prior Authorization Request

Essential Components

Patient Information:

  • Full name, DOB, Humana member ID
  • Current weight in kg with date recorded
  • Diagnosis: Idiopathic multicentric Castleman disease (ICD-10: D47.Z2)

Clinical Documentation:

  • Pathology report confirming Castleman disease
  • Imaging showing multicentric lymphadenopathy
  • Laboratory results showing systemic inflammation
  • HIV test results: NEGATIVE (with date)
  • HHV-8 test results: NEGATIVE (with date)

Prescription Details:

  • Drug: Sylvant (siltuximab)
  • Dose: 11 mg/kg (calculate exact mg amount)
  • Frequency: Every 3 weeks
  • Route: IV infusion
  • Duration: Until treatment failure or unacceptable toxicity

Submission Method: Submit through Humana's provider portal or by fax. Include all supporting documentation as PDF attachments.

Common Coding and Billing Pitfalls

Error Type Common Mistake Correction
Unit Calculation Using total mg as units Divide total dose by 10 (J2860 = 10 mg per unit)
Weight Conversion Rounding errors in lb to kg Use precise conversion: lbs ÷ 2.20462
NDC Selection Wrong vial size code Match NDC to actual vial(s) used
Frequency Billing monthly Sylvant is dosed every 3 weeks (21 days)
Documentation Missing HIV/HHV-8 results Must document both negative tests
Lab Requirements Outdated lab values CBC required before each dose (first 12 months)

Billing Error Example

❌ Incorrect: 770 mg dose billed as 770 units ✅ Correct: 770 mg dose billed as 77 units (770 ÷ 10 = 77)

Humana Verification and Resources

Before Submitting

  1. Check PA Requirements: Use Humana's prior authorization search tool to confirm Sylvant requires prior authorization
  2. Verify Coverage: Confirm the drug is covered under medical benefit
  3. Review Medical Policy: Access current Humana medical policies for specialty drugs

Submission Timeline

  • Standard Review: Up to 30 days for Medicare Advantage
  • Expedited Review: 72 hours if medically urgent
  • Electronic Submission: Response within 1 business day for most requests
Clinician Corner: When writing medical necessity letters, emphasize that iMCD is a life-threatening systemic disorder with no FDA-approved alternatives to siltuximab for this specific indication. Include references to the FDA prescribing information and current treatment guidelines.

Appeals Process in Virginia

Internal Appeals with Humana

Timeline: 65 days from denial notice Levels:

  1. Standard Appeal: Submit through member portal or by mail
  2. Expedited Appeal: For urgent medical situations (72-hour decision)

Virginia External Review

If Humana's internal appeal is denied, Virginia residents can request external review through the State Corporation Commission (SCC).

Key Details:

  • Deadline: 120 days from Humana's final denial
  • Cost: Free to patients
  • Timeline: 45 days for standard review, 72 hours for expedited
  • Eligibility: Medical necessity denials (not formulary or administrative denials)

How to File:

  1. Complete External Review Request Form 216-A
  2. Submit by mail, fax (804-371-9915), or email ([email protected])
  3. Include Humana's final denial letter and supporting medical records

Contact Information: Virginia State Corporation Commission
Bureau of Insurance
P.O. Box 1157
Richmond, VA 23218

Virginia Advantage: The state's external review process has helped many patients overturn specialty drug denials. Independent medical reviewers often have different perspectives than insurance company reviewers.

At Counterforce Health, we help patients and clinicians navigate these complex prior authorization and appeals processes by turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and crafts point-by-point rebuttals using the right clinical evidence and payer-specific requirements.

Quick Pre-Submission Checklist

Before submitting your Sylvant prior authorization:

☐ Patient weight documented in kg with current date
☐ ICD-10 code D47.Z2 confirmed for Castleman disease
☐ HIV test results documented as negative
☐ HHV-8 test results documented as negative
☐ Pathology report confirming Castleman disease histology
☐ Imaging results showing multicentric lymphadenopathy
☐ Laboratory values showing systemic inflammation
☐ Dose calculation verified: weight (kg) × 11 mg/kg
☐ HCPCS units calculated: total mg ÷ 10
☐ NDC numbers match vial sizes to be used
☐ Frequency specified as every 3 weeks (not monthly)
☐ Medical necessity letter includes FDA indication and clinical rationale

FAQ

Q: How long does Humana prior authorization take for Sylvant?
A: Standard review takes up to 30 days for Medicare Advantage plans. Expedited review (for urgent cases) takes 72 hours.

Q: What if Sylvant is not on Humana's formulary?
A: Since Sylvant is administered in clinical settings, it's typically covered under medical benefit rather than pharmacy formulary. Prior authorization focuses on medical necessity rather than formulary status.

Q: Can I request expedited appeal if my condition is urgent?
A: Yes, if your physician certifies that waiting for standard review could seriously jeopardize your health, you can request expedited internal appeal (72 hours) and expedited external review in Virginia (72 hours).

Q: What happens if I start treatment before approval?
A: You may be responsible for the full cost. Some plans offer retroactive coverage if medical necessity is later established, but this varies by policy.

Q: Does step therapy apply to Sylvant for iMCD?
A: Typically no, since Sylvant is the only FDA-approved treatment for iMCD. However, some plans may require documentation that the diagnosis is confirmed and other conditions are ruled out.

Q: How often do I need new prior authorization?
A: Most plans approve Sylvant for 6-month periods with renewal based on continued medical necessity and treatment response.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with healthcare professionals and verify current insurance policies and state regulations. Coverage decisions are made by insurance companies based on individual medical circumstances and plan terms. For personalized assistance with prior authorization and appeals, consider working with experienced healthcare advocates like those at Counterforce Health.

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