By Counterforce Health Team in Bavencio (avelumab) —

The Requirements Checklist to Get Bavencio (avelumab) Covered by Blue Cross Blue Shield in California

Answer Box: Getting Bavencio Covered by Blue Cross Blue Shield in California

Bavencio (avelumab) requires prior authorization from Blue Cross Blue Shield in California for metastatic Merkel cell carcinoma and urothelial carcinoma. Your fastest path to approval: 1) Gather complete diagnosis records and prior treatment history, 2) Submit the PA request through Blue Shield's AuthAccel portal with medical necessity documentation, 3) If denied, file an internal appeal within 60 days, then request a California Independent Medical Review (IMR) through the DMHC Help Center. Success rate for oncology drug appeals in California: approximately 70% of Blue Cross denials are overturned on external review.

Table of Contents

Who Should Use This Checklist

This guide is designed for patients with metastatic Merkel cell carcinoma or locally advanced/metastatic urothelial carcinoma who need Bavencio (avelumab) covered by Blue Cross Blue Shield plans in California. You'll also find this useful if you're a caregiver, oncology nurse, or clinic staff member handling prior authorizations.

Expected outcome: Following this checklist increases your approval chances significantly. California patients have strong appeal rights—roughly 70% of Blue Cross oncology drug denials are overturned when proper documentation is provided through the state's Independent Medical Review process.

Member & Plan Basics

Before starting your prior authorization request, verify these essential details:

Coverage Verification

  • Active enrollment: Confirm your Blue Shield of California coverage is current
  • Plan type: Most HMO and PPO plans require PA for Bavencio
  • Deductible status: Provider-administered drugs like Bavencio typically count toward your medical deductible, not pharmacy
  • Network status: Ensure your oncologist and infusion center are in-network

Authorization Requirements

Blue Shield of California requires prior authorization for all Bavencio requests as of 2024. The drug is classified as a specialty medication under the medical benefit, not pharmacy benefit, since it's administered by IV infusion.

Note: Unlike oral specialty drugs, Bavencio doesn't go through Blue Shield's specialty pharmacy network. Coverage is managed through your medical benefits at in-network provider facilities.

Clinical Criteria Requirements

Blue Shield of California follows specific medical necessity criteria for Bavencio coverage:

FDA-Approved Indications

  • Metastatic Merkel cell carcinoma (first-line or subsequent therapy)
  • Locally advanced or metastatic urothelial carcinoma (maintenance treatment after first-line platinum-based chemotherapy without progression)

Required Clinical Documentation

Your oncologist must provide evidence of:

  1. Confirmed diagnosis with pathology reports
  2. Appropriate disease stage (metastatic MCC or advanced UC)
  3. Prior treatment history for urothelial carcinoma patients (must have received platinum-based chemotherapy)
  4. Performance status and ability to tolerate treatment
  5. No contraindications to checkpoint inhibitor therapy

Step Therapy Considerations

  • Merkel cell carcinoma: Typically no step therapy required
  • Urothelial carcinoma: Must document platinum-based chemotherapy as first-line treatment

Coding & Billing Essentials

Accurate coding is crucial for approval. Use these specific codes:

HCPCS/Billing Codes

  • J9023: Injection, avelumab, 10 mg (primary billing code)
  • CPT 96413: IV infusion administration, up to 1 hour
  • NDC: 44087-3535-01 (if required by payer)

ICD-10 Diagnosis Codes

For Merkel Cell Carcinoma:

  • C4A.0–C4A.9 (site-specific codes)
  • C7B.1 (secondary Merkel cell carcinoma)

For Urothelial Carcinoma:

  • C67.0–C67.9 (bladder)
  • C65.1–C65.9 (renal pelvis)
  • C66.1–C66.9 (ureter)
Tip: Use the most specific anatomic location code available. Vague coding often triggers automatic denials.

Documentation Packet

Your prior authorization packet should include these essential components:

Medical Necessity Letter Elements

Your oncologist should include:

  1. Patient demographics and insurance information
  2. Complete diagnosis with staging and pathology confirmation
  3. Treatment history including dates, responses, and reasons for discontinuation
  4. Clinical rationale for Bavencio specifically
  5. FDA indication alignment and guideline support
  6. Monitoring plan for response and toxicity
  7. Physician signature and contact information

Required Attachments

  • Recent pathology reports
  • Imaging studies showing disease extent
  • Previous treatment records and outcomes
  • Current performance status assessment
  • Laboratory values (if relevant to safety)

Supporting Evidence

Reference current treatment guidelines:

Submission Process

Correct Forms and Portals

  • Provider submission: Use Blue Shield's AuthAccel portal or designated PA forms
  • Required fields: Complete all sections—incomplete forms are automatically rejected
  • Submission method: Electronic submission preferred; fax as backup

Timeline Expectations

  • Standard review: 5-14 business days
  • Expedited review: 72 hours (if urgent medical need documented)
  • Confirmation: Save all confirmation numbers and submission receipts

Common Submission Errors to Avoid

  1. Incomplete diagnosis codes or missing pathology
  2. Insufficient prior treatment documentation for urothelial carcinoma
  3. Wrong billing codes or outdated NDC numbers
  4. Missing physician attestation or unsigned forms
  5. Inadequate medical necessity justification

After Submission: What to Expect

Status Monitoring

  • Check status: Use Blue Shield's provider portal or call member services
  • Document everything: Keep records of all confirmation numbers and communications
  • Follow up: If no response within stated timeframes, contact the plan directly

Approval Process

If approved, you'll receive:

  • Written authorization with specific terms
  • Approved quantity and duration
  • Any special requirements or restrictions

Common Denial Prevention Tips

Based on California appeal data, here are the top five denial reasons and how to prevent them:

Common Denial Reason Prevention Strategy
Insufficient medical necessity Include detailed clinical rationale with guideline citations
Missing prior treatment history Document all previous therapies with dates and outcomes
Incorrect diagnosis coding Use most specific ICD-10 codes with pathology confirmation
Off-label use concerns Clearly document FDA-approved indication alignment
Incomplete documentation Submit comprehensive packet with all required attachments

Appeals Process for California

If your initial request is denied, California offers robust appeal rights:

Internal Appeal (First Level)

  • Timeline: File within 60 days of denial
  • Process: Submit additional documentation addressing denial reasons
  • Decision: Plan has 30 days to respond

Independent Medical Review (IMR)

California's external review process offers excellent success rates for oncology drugs:

How to File an IMR

  1. Contact DMHC: Call the Help Center at 888-466-2219
  2. Submit application: Use the online IMR application
  3. Provide records: Include all medical documentation and denial letters
  4. Await decision: Independent physicians review your case
From our advocates: "We've seen California patients successfully overturn Bavencio denials by providing comprehensive treatment histories and clear documentation of disease progression. The key is showing that standard treatments were tried and failed, and that Bavencio meets the specific FDA indication criteria."

Quick Reference Checklist

Print this checklist and check off each item before submission:

Before You Start:

  • Verify active Blue Shield coverage
  • Confirm oncologist is in-network
  • Gather all medical records

Clinical Requirements:

  • Pathology report confirming diagnosis
  • Staging documentation (metastatic MCC or advanced UC)
  • Prior treatment history (especially for UC patients)
  • Current imaging studies
  • Performance status assessment

Documentation:

  • Complete medical necessity letter
  • Correct ICD-10 and HCPCS codes
  • All required attachments
  • Physician signature and date

Submission:

  • Use correct PA form or portal
  • Double-check all fields are complete
  • Save confirmation numbers
  • Set calendar reminder for follow-up

FAQ

Q: How long does Blue Cross Blue Shield prior authorization take in California? A: Standard review takes 5-14 business days. Expedited review (for urgent cases) takes up to 72 hours.

Q: What if Bavencio is not on my plan's formulary? A: Since Bavencio is a provider-administered drug, formulary status is less relevant. Coverage is determined through medical necessity review under your medical benefits.

Q: Can I request an expedited appeal if denied? A: Yes, if you can document urgent medical need. Both internal appeals and California's IMR process offer expedited options.

Q: Do I need to try other treatments first? A: For Merkel cell carcinoma, typically no. For urothelial carcinoma, you must have received first-line platinum-based chemotherapy.

Q: What happens if Blue Cross doesn't respond within their timeframe? A: In California, you can proceed directly to Independent Medical Review if the plan fails to respond within 30 days.

Q: Are there financial assistance options while appealing? A: Check Bavencio's manufacturer website for patient assistance programs. Some foundations also provide grants for cancer treatments during appeals.

For complex cases requiring detailed appeal preparation, Counterforce Health helps patients and clinicians turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned to each payer's specific requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for personalized guidance. Coverage policies and requirements may change—verify current information with your specific Blue Cross Blue Shield plan.

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