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    v1.0.31
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsAmeriHealth Tezspire Coverage Update | OpenPayer
    Ask Trek AI about this page
    ModifiedAmeriHealth Caritas VIP CarePolicy MA08.144c

    Tezepelumab-ekko (Tezspire) Coverage Criteria

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    Medical-benefit coverage and medical necessity for tezepelumab-ekko in Medicare Advantage members with severe asthma or chronic rhinosinusitis with nasal polyposis, subject to Evidence of Coverage and clinical criteria.

    Policy Summary
    PayerAmeriHealth Caritas VIP Care
    PolicyTezepelumab-ekko (Tezspire) Coverage Criteria
    Policy CodePolicy MA08.144c
    Change TypeModified
    Effective DateSeptember 18, 2026
    Last ReviewMar 28, 2025
    Next Review DateN/A
    Key ActionDocument medical necessity for tezepelumab-ekko and make supporting medical records available upon request.
    SourceLink
    POLICY UPDATE CHANGES

    Chronic rhinosinusitis with nasal polyposis was added as a medically necessary indication for tezepelumab-ekko.

    ICD-10 codes for chronic sinusitis and nasal polyps were added to the policy.

    The policy history documents deletion of HCPCS codes J3590 and C9399 and addition of HCPCS code J2356 for tezepelumab-ekko.

    The policy was reissued through annual review processes, with a prior review noting that the policy intent remained unchanged.

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    12+Minimum age
    11CRSwNP diagnosis codes
    J2356Current injection code
    210 mg q4wDose
    2Deleted HCPCS codes

    Coverage Criteria

    Severe asthma initial therapy

    Covered when all of the following are met for add-on maintenance treatment of severe asthma.

    • Age and severe-asthma treatment: The individual is aged 12 years or older; prebronchodilator FEV1 is below 80% predicted in adults or below 90% predicted in adolescents; and the individual regularly receives medium- or high-dose inhaled corticosteroids, unless contraindicated or intolerant, plus at least one additional asthma controller for 3 months or more. Additional controllers may include a LABA, LAMA, or leukotriene modifier.Age ≥12 years; FEV1 <80% predicted in adults or <90% in adolescents; controller therapy ≥3 months

      Background asthma therapy must continue during treatment. Oral corticosteroids may or may not be used.

    • Exacerbation history

      • The individual has a history of two or more asthma exacerbations requiring oral or injectable corticosteroid treatment.≥2 corticosteroid-treated exacerbations in the past 12 months
      • The individual has a history of one asthma exacerbation resulting in hospitalization.≥1 hospitalization for an exacerbation in the past 12 months

    Severe asthma continuation therapy

    Covered for continuation therapy when any of the following is documented.

    Severe asthma continuation response

    • Clinical improvement in the individual's asthma symptoms.
    • An increase in FEV1 from the pretreatment baseline.
    • Decreased utilization of rescue medication.

    CRSwNP initial therapy

    Covered when all of the following are met for add-on maintenance treatment of chronic rhinosinusitis with nasal polyposis.

    • Age, duration, severity, and symptoms: The individual is aged 12 years or older with inadequately controlled chronic rhinosinusitis with nasal polyposis for at least 12 months; total NPS is 5 or more, with a score of 2 or more for each nostril; NCS is 2 or more; and ongoing nasal-polyp symptoms have been documented for more than 8 weeks.Age ≥12 years; CRSwNP ≥12 months; NPS ≥5 with ≥2 per nostril; NCS ≥2; symptoms >8 weeks

      Severity must be consistent with need for surgery. Symptoms may include rhinorrhea or reduction/loss of smell.

    • Treatment history

      • The individual continues treatment with intranasal corticosteroids.
      • The individual has any history of nasal-polyp surgery.

    CRSwNP continuation therapy

    Covered for continuation therapy when any of the following is documented.

    CRSwNP continuation response

    • Clinical improvement in nasal polyp score (NPS).
    • Improvement in nasal congestion score (NCS).
    • Improvement in nasal-polyp symptoms.

    Chronic rhinosinusitis with nasal polyposis

    Tezepelumab-ekko is medically necessary for chronic rhinosinusitis with nasal polyposis when both a qualifying chronic sinusitis diagnosis and at least one qualifying nasal polyp diagnosis are reported.

    • Qualifying chronic sinusitis diagnosis

      • Report at least one of the following chronic sinusitis diagnoses: J32.0 chronic maxillary sinusitis; J32.1 chronic frontal sinusitis; J32.2 chronic ethmoidal sinusitis; J32.3 chronic sphenoidal sinusitis; J32.4 chronic pansinusitis; J32.8 other chronic sinusitis; or J32.9 chronic sinusitis, unspecified.

    • Qualifying nasal polyp diagnosis

      • Report at least one of the following nasal polyp diagnoses: J33.0 polyp of nasal cavity; J33.1 polypoid sinus degeneration; J33.8 other polyp of sinus; or J33.9 nasal polyp, unspecified.

    All other uses of tezepelumab-ekko (Tezspire) are considered experimental/investigational and are not covered unless the indication is supported as an accepted off-label use under the applicable medical policy for off-label coverage of prescription drugs and biologics.

    The safety and effectiveness of tezepelumab-ekko (Tezspire) have not been established for any indication in pediatric individuals less than 12 years of age.

    Coding and Clinical Thresholds

    CPT Procedure CodesCPT
    N/ANo CPT procedure codes listed
    ICD-10 Procedure CodesICD-10
    N/ANo ICD-10 procedure codes listed
    ICD-10 Diagnosis CodesICD-10Covered
    J45.50Severe persistent asthma, uncomplicated
    J45.51Severe persistent asthma with (acute) exacerbation
    J82.83Eosinophilic asthma
    Covered Chronic Sinusitis Diagnosis CodesICD-10Covered
    J32.0Chronic maxillary sinusitis
    J32.1Chronic frontal sinusitis
    J32.2Chronic ethmoidal sinusitis
    J32.3Chronic sphenoidal sinusitis
    J32.4Chronic pansinusitis
    J32.8Other chronic sinusitis
    J32.9Chronic sinusitis, unspecified
    Covered Nasal Polyp Diagnosis CodesICD-10Covered
    J33.0Polyp of nasal cavity
    J33.1Polypoid sinus degeneration
    J33.8Other polyp of sinus
    J33.9Nasal polyp, unspecified
    HCPCS Level II CodesHCPCSCovered
    J2356Injection, tezepelumab-ekko, 1 mg
    Revenue CodesRevenue
    N/ANo revenue codes listed
    Added HCPCS CodeHCPCSCovered
    J2356Injection, tezepelumab-ekko, 1 mg
    Deleted HCPCS CodesHCPCSNot Covered
    J3590Unclassified biologics
    C9399Unclassified drugs or biologicals
    Adult prebronchodilator FEV1
    MeasurePrebronchodilator forced expiratory volume in 1 second (FEV1)
    Adult thresholdBelow 80 percent predicted
    ApplicationRequired for severe asthma initial therapy in adults aged 12 years and older
    Adolescent prebronchodilator FEV1
    MeasurePrebronchodilator forced expiratory volume in 1 second (FEV1)

    Provider Documentation and Action Items

    Documentation Required

    Medical Necessity Records Required

    Maintain medical records demonstrating the medical necessity of tezepelumab-ekko (Tezspire) and make all supporting documentation available to AmeriHealth Caritas upon request.

    • Documentation may include records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.
    • The Company may review and audit services regardless of the provider's participation status.
    Documentation Required

    Document Asthma Continuation Response

    For continuation therapy for severe asthma, document clinical improvement or another qualifying response before continued treatment is authorized.

    • Clinical improvement in asthma symptoms
    • Increase in FEV1 from pretreatment baseline
    • Decreased utilization of rescue medication

    Clinical Background

    Tezepelumab-ekko is a human monoclonal antibody that binds thymic stromal lymphopoietin (TSLP), an upstream cytokine involved in airway and nasal inflammation. It is used as add-on maintenance treatment for severe asthma and chronic rhinosinusitis with nasal polyposis.

    Clinical Measure Definitions

    Nasal polyp score (NPS)
    DefinitionThe sum of the polyp-size scores from both nostrils
    Assessment methodEvaluate both nostrils by nasal endoscopy
    Per-nostril scaleEach nostril is scored from 0 (no polyp) through 4 (large polyps causing complete or near-complete obstruction of the inferior nasal cavity)
    Nasal congestion score (NCS)
    DefinitionThe individual's rating of the severity of their worst nasal congestion
    Assessment periodThe previous 24 hours
    Severity scale

    Initial Therapy Criteria

    Severe asthma initial therapy

    Covered for add-on maintenance treatment of severe asthma when all of the following are met.

    • The individual is aged 12 years or older.
    • The individual has severe asthma with prebronchodilator FEV1 below 80% predicted in adults or below 90% predicted in adolescents.FEV1 <80% predicted in adults or <90% in adolescents
    • The individual regularly receives medium- or high-dose inhaled corticosteroids, unless contraindicated or intolerant, plus at least one additional asthma controller for 3 months or more. Additional controllers may include a LABA, LAMA, or leukotriene modifier.Controller therapy ≥3 months

    • Exacerbation history

    Continuation Criteria

    Severe asthma continuation

    Covered for severe asthma continuation therapy when documentation confirms any one response criterion.

    Severe asthma continuation response

    • Clinical improvement in asthma symptoms.
    • An increase in FEV1 from pretreatment baseline.
    • Decreased rescue-medication utilization.

    CRSwNP continuation

    Covered for CRSwNP continuation therapy when documentation confirms any one response criterion.

    CRSwNP continuation response

    Dosage and Quantity Limits

    Tezepelumab-ekko (Tezspire)
    MedicationTezepelumab-ekko (Tezspire)
    Dose210 mg
    Schedule and routeSubcutaneous injection once every 4 weeks

    Administration Site and Method

    Billing Rule

    Use the required office administration setting

    Administer tezepelumab-ekko by subcutaneous injection through a healthcare professional provider in the office setting.

    Policy Summary
    PayerAmeriHealth Caritas VIP Care
    PolicyTezepelumab-ekko (Tezspire) Coverage Criteria
    Policy CodePolicy MA08.144c
    Change TypeModified
    Effective DateSeptember 18, 2026
    Last ReviewMar 28, 2025
    Next Review DateN/A
    Key ActionDocument medical necessity for tezepelumab-ekko and make supporting medical records available upon request.
    SourceLink
    On This Page
    Coverage CriteriaCoding and Clinical ThresholdsProvider Documentation and Action ItemsClinical BackgroundClinical Measure DefinitionsInitial Therapy CriteriaContinuation CriteriaDosage and Quantity LimitsAdministration Site and Method
    The individual has a contraindication or intolerance to nasal-polyp surgery.
    Adolescent thresholdBelow 90 percent predicted
    ApplicationRequired for severe asthma initial therapy in adolescents aged 12 years and older
    Asthma controller duration
    Inhaled corticosteroidRegular medium- or high-dose inhaled corticosteroid (ICS) treatment, unless contraindicated or intolerant
    Additional controllerAt least one additional asthma controller, such as a LABA inhaler, LAMA inhaler, or leukotriene modifier
    Minimum duration3 months or more
    Asthma exacerbation history
    Required historyA history of one qualifying asthma outcome is required
    Corticosteroid-treated exacerbationsTwo or more asthma exacerbations requiring oral or injectable corticosteroid treatment
    Hospitalization alternativeOne asthma exacerbation resulting in hospitalization in the past 12 months
    CRSwNP duration
    ConditionChronic rhinosinusitis with nasal polyposis (CRSwNP)
    Control statusInadequately controlled
    Minimum durationAt least 12 months
    Total nasal polyp score
    Total scoreAt least 5
    Per-nostril requirementAt least 2 for each nostril
    Clinical contextSeverity consistent with the need for surgery
    Nasal congestion score
    MeasureNasal congestion score (NCS)
    Minimum scoreAt least 2
    Clinical contextRequired for CRSwNP initial therapy
    Nasal-polyp symptoms
    SymptomsOngoing documented nasal-polyp symptoms
    Minimum durationGreater than 8 weeks
    ExamplesRhinorrhea or reduction/loss of smell
    Documentation Required

    Document CRSwNP Continuation Response

    For continuation therapy for CRSwNP, document improvement in at least one qualifying disease measure.

    • Clinical improvement in nasal polyp score (NPS)
    • Improvement in nasal congestion score (NCS)
    • Improvement in nasal polyp symptoms
    Denial Risk

    Noncovered Uses

    All other uses of tezepelumab-ekko (Tezspire) are considered experimental/investigational and are not covered unless the indication qualifies as an accepted off-label use under the medical policy for off-label coverage of prescription drugs and biologics.

    Denial Risk

    Insufficient Documentation May Result in Denial

    Ensure the medical record and supporting documentation demonstrate medical necessity and are available upon request. Failure to produce requested information may result in denial of the drug.

    Denial Risk

    Age Below 12 Years

    The safety and effectiveness of tezepelumab-ekko (Tezspire) have not been established for any indication in pediatric individuals younger than 12 years.

    • Established pediatric use begins at age 12 for add-on maintenance treatment of severe asthma and CRSwNP.
    Billing Rule

    Required Paired Diagnoses for CRSwNP

    Claims for tezepelumab-ekko for chronic rhinosinusitis with nasal polyposis must report a qualifying chronic sinusitis diagnosis and at least one qualifying nasal polyp diagnosis.

    • Chronic sinusitis: J32.0 Chronic maxillary sinusitis; J32.1 Chronic frontal sinusitis; J32.2 Chronic ethmoidal sinusitis; J32.3 Chronic sphenoidal sinusitis; J32.4 Chronic pansinusitis; J32.8 Other chronic sinusitis; or J32.9 Chronic sinusitis, unspecified.
    • At least one nasal polyp diagnosis: J33.0 Polyp of nasal cavity; J33.1 Polypoid sinus degeneration; J33.8 Other polyp of sinus; or J33.9 Nasal polyp, unspecified.
    0 (none), 1 (mild), 2 (moderate), and 3 (severe)
    SNOT-22
    NameSino-Nasal Outcome Test-22 (SNOT-22)
    FormatValidated 22-item questionnaire
    PurposeAssesses sino-nasal quality of life; higher scores indicate greater disease burden
    Nasal polyp score (NPS)
    MeasureNasal polyp size
    Score range0 to 8
    Assessment methodTotal nasal polyp score is assessed by nasal endoscopy
    Nasal congestion score (NCS)
    MeasureNasal congestion severity
    Score range0 to 3
    Assessment methodAssessed using a symptom diary
  1. Two or more asthma exacerbations requiring oral or injectable corticosteroid treatment in the past 12 months.≥2 exacerbations
  2. One asthma exacerbation resulting in hospitalization in the past 12 months.≥1 hospitalization

    3. CRSwNP initial therapy

    Covered for add-on maintenance treatment of CRSwNP when all of the following are met.

    • The individual is aged 12 years or older with inadequately controlled chronic rhinosinusitis with nasal polyposis for at least 12 months.CRSwNP ≥12 months
    • Disease severity is consistent with need for surgery, defined by a total nasal polyp score of 5 or more, with a score of 2 or more for each nostril.NPS ≥5 with ≥2 per nostril
    • Nasal congestion score is 2 or more.NCS ≥2
    • Ongoing nasal-polyp symptoms have been documented for more than 8 weeks, such as rhinorrhea or reduction/loss of smell.Symptoms >8 weeks

    • Treatment history

      • Continuation of treatment with intranasal corticosteroids.
      • Any history of nasal-polyp surgery.
      • A contraindication or intolerance to nasal-polyp surgery.

    Initial therapy: chronic rhinosinusitis with nasal polyposis

    Initial coverage for chronic rhinosinusitis with nasal polyposis requires both a chronic sinusitis diagnosis and at least one nasal polyp diagnosis.

    Qualifying paired diagnoses

    • Chronic sinusitis diagnosis

      • Report at least one of: J32.0 chronic maxillary sinusitis; J32.1 chronic frontal sinusitis; J32.2 chronic ethmoidal sinusitis; J32.3 chronic sphenoidal sinusitis; J32.4 chronic pansinusitis; J32.8 other chronic sinusitis; or J32.9 chronic sinusitis, unspecified.

    • Nasal polyp diagnosis

      • Report at least one of: J33.0 polyp of nasal cavity; J33.1 polypoid sinus degeneration; J33.8 other polyp of sinus; or J33.9 nasal polyp, unspecified.
    Clinical improvement in nasal polyp score (NPS).
  3. Improvement in nasal congestion score (NCS).
  4. Improvement in nasal-polyp symptoms.