CurrentEmpire BluecrossPolicy ING-CC-0006

Clinical criteria index and code mappings for specialty pharmacy

Lists clinical criteria document numbers, drug names, and associated HCPCS/CPT codes for numerous specialty pharmacy products as part of Empire Bluecross policy ING-CC-0006 and related documents; intended for providers and pharmacy administrators to identify which clinical criteria documents apply to each drug and code.

Policy Summary

PayerEmpire Bluecross

PolicyClinical criteria index and code mappings for specialty pharmacy

Policy CodePolicy ING-CC-0006

Change TypeIndex / mapping update

Effective DateMar 1, 2019

Next Review Date

Key ActionWhen requesting prior authorization or submitting claims, reference the appropriate ING-CC or DRUG clinical criteria document number associated with the drug and HCPCS/CPT code.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~100+drug or clinical-criteria entries listed

multipleHCPCS/CPT codes referenced

ING-CC-0006primary clinical criteria doc

Coverage & Index Summary

General coverage direction

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Index mapping: Refer to the named ING-CC or DRUG clinical criteria document number for full coverage criteria for each drug and HCPCS/CPT code listed in this index.

This index file lists mappings from drugs and codes to clinical criteria document numbers; the detailed medical necessity criteria are contained in the referenced ING-CC/DRUG documents (for example, ING-CC-0006 for Hyaluronan Injections and ING-CC-0011 for Ocrevus).

This index document does not list explicit clinical exclusions. Coverage and any exclusionary rules for a given product are contained within the referenced clinical criteria documents (for example, ING-CC-0006 and the DRUG-designated clinical criteria referenced in the mappings). Providers should consult the specific ING-CC or DRUG clinical criteria document identified for each drug and HCPCS/CPT code to determine applicable exclusions.

The document does not define specific situations that are 'not medically necessary.' Determinations about when a service or drug is not medically necessary are made by the detailed clinical criteria in the named ING-CC or DRUG documents referenced in this index (for example, ING-CC-0006 and other listed document numbers). Refer to the individual clinical criteria document for any 'not medically necessary' language and guidance.

HCPCS / CPT / Q-code Index

Hyaluronan injections codesHCPCS

J7322	HCPCS code listed for hyaluronan injections (document lists J7322)
J7323	HCPCS code listed for hyaluronan injections (document lists J7323)
J7324	HCPCS code listed for hyaluronan injections (document lists J7324)
J7328	HCPCS code listed for hyaluronan injections (document lists J7328)
J7329	HCPCS code listed for hyaluronan injections (document lists J7329)

OcrevusHCPCS

J2350

HCPCS code listed for Ocrevus (ocrelizumab)

BrineuraHCPCS

J0567

HCPCS code listed for Brineura (cerliponase alfa)

Multiple (J3490 usages)HCPCS

J3490

General HCPCS unlisted drug code referenced for multiple drugs

Enzyme / biologic agentsHCPCS

J2323	HCPCS code listed for Tysabri (natalizumab)
J0180	HCPCS code listed for Fabrazyme (agalsidase beta)
J1322	HCPCS code listed for Vimizim (elosulfase alfa)

Various mapped HCPCS/CPT codesHCPCS

J1458	Previously mapped HCPCS in earlier mapping lines; appears as source code being replaced/mapped to many specific J-codes
J1743	Mapped HCPCS code (example mapping from J1458)
J1931	Mapped HCPCS code (example mapping from J1458)
J0897	Mapped HCPCS code (example mapping from J1458)
J0490	Mapped HCPCS code (example mapping from J1458)
J0570	Mapped HCPCS code (example mapping from J1458)
J2278	HCPCS code listed for Prialt (ziconotide)
J1300	HCPCS code listed for Soliris (eculizumab)
C9399	HCPCS miscellaneous code referenced
J2357	HCPCS code listed for Xolair (omalizumab)

1–10 of 15

1/2

Q-codesHCPCS

Q9991	Q-code referenced in mapping lines
Q9992	Q-code referenced in mapping lines

What Providers Need to Do

Prior Authorization

Prior Authorization Required

Prior authorization is required and is tied to the listed clinical criteria documents for the specialty drugs and their HCPCS/CPT codes. Providers must reference the associated clinical criteria document number (for example, ING-CC-0006 and other ING-CC/DRUG codes) when submitting prior authorization requests.

Associated HCPCS/CPT codes must match the clinical criteria document (e.g., J7322, J7323, J7324, J7328, J7329 are linked to ING-CC-0006 for Hyaluronan injections).

Note

Provider note: consult the clinical criteria document referenced for each drug when preparing documentation and submitting a prior authorization request to ensure completeness and avoid processing delays.

Documentation Required

Reference Clinical Criteria Document Numbers

When submitting claims or prior authorization requests, providers should include the listed clinical criteria document number(s) (for example, ING-CC-0006, ING-CC-0007, ING-CC-0008, etc.) that correspond to the drug and HCPCS/CPT code being billed.

Include the clinical criteria document number on the PA submission and related medical documentation.

Denial Risk

Claims May Be Reviewed or Denied

Claims submitted without matching HCPCS/CPT codes to the listed clinical criteria documents may be subject to review or denial. Ensure the billed code corresponds to the clinical criteria document associated with the drug.

Claims with codes that do not match an associated ING-CC document (for example, billing a code not listed for the drug's clinical criteria) risk denial or additional review.

Document Purpose & Scope

This index-style update (effective March 1, 2019) lists the payer clinical criteria document identifiers and associated specialty products and codes. Examples include CG-DRUG-29 / ING-CC-0006 for Hyaluronan injections (Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, SupartzIFX, Synviscl-One, TriVisc, Visco-3) mapped to HCPCS codes J7322, J7323, J7324, J7328, J7329, and DRUG.00095 / ING-CC-0011 for Ocrevus (ocrelizumab). The file functions as a mapping tool to identify which ING-CC or DRUG clinical criteria document governs coverage and prior authorization for each listed specialty drug and its HCPCS/CPT code(s).

Key Terms & Document Identifiers

ING-CC / DRUG document numbers — internal clinical criteria identifiers

Primary clinical criteria documentING-CC-0006

Associated clinical criteria name (example)Hyaluronan Injections (CG-DRUG-29)

Representative drugs mappedDurolane; Euflexxa; Gel-One; Gen-Syn; GenVisc; Hyalgan; Hymovis; Monovisc; Orthovisc; SupartzIFX; Synviscl-One; TriVisc; Visco-3

Representative HCPCS/CPT codes mapped to ING-CC-0006J7322, J7323, J7324, J7328, J7329

Other ING-CC/DRUG document numbers present in indexING-CC-0007, ING-CC-0008, ING-CC-0009, ING-CC-0010, ING-CC-0011

Initial Therapy Direction

Initial therapy direction

Index guidance: Initial therapy and specific coverage criteria are defined in each referenced ING-CC or DRUG clinical criteria document for the named product.

See the specific document number listed for each drug (e.g., ING-CC-0006 for Hyaluronan Injections). This index does not contain disease- or site-specific initial therapy rules.