CurrentEmpire BluecrossPolicy ING-CC-0006

Clinical criteria index for specialty pharmacy (ING-CC-0006)

Lists clinical criteria document numbers, drug names, and associated HCPCS/CPT codes for numerous specialty pharmacy products; governs prior authorization and coverage mapping for Empire BlueCross providers and pharmacy administrators.

Policy Summary

PayerEmpire Bluecross

PolicyClinical criteria index for specialty pharmacy (ING-CC-0006)

Policy CodePolicy ING-CC-0006

Change TypeIndex publication (no material clinical changes)

Effective DateMar 1, 2019

Next Review Date

Key ActionProvide the appropriate ING-CC clinical criteria document number and associated HCPCS/CPT code(s) with prior authorization requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~80+drug-specific clinical criteria entries referenced

multipleHCPCS/CPT codes listed

INDIVIDUALpolicy covers drugs

Coverage & Medical Necessity Links

General coverage linkage

Coverage and medical necessity determinations are governed by the referenced clinical criteria documents (ING-CC-####) for each listed drug or drug group.

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HCPCS / CPT Code Mappings

Hyaluronan injections (examples)HCPCS

J7322	HCPCS code listed for hyaluronan injections group
J7323	HCPCS code listed for hyaluronan injections group
J7324	HCPCS code listed for hyaluronan injections group
J7328	HCPCS code listed for hyaluronan injections group
J7329	HCPCS code listed for hyaluronan injections group

Selected specialty biologic HCPCS codesHCPCS

J2323	Tysabri (natalizumab)
J2350	Ocrevus (ocrelizumab)
J0567	Brineura (cerliponase alfa)
J3490	Unspecified biologics / miscellaneous — used for several agents
J3590	Unspecified biologics / miscellaneous — used for several agents
J0202	Lemtrada (alemtuzumab)

Botulinum toxin and Q-codesHCPCS

J0585	Botulinum toxin code listed
J0586	Botulinum toxin code listed
J0587	Botulinum toxin code listed
J0588	Botulinum toxin code listed
Q9991	Specific Q-code listed
Q9992	Specific Q-code listed

Various specialty drug codes (group mapping)HCPCS

J1428	Index code used repeatedly to map Exondys 51 group entries to multiple drugs
J1300	Soliris (eculizumab)
J2507	Krystexxa (pegloticase)
J2353	Octreotide (Sandostatin) related
J2354	Octreotide LAR related

Prior Authorization & Billing Requirements

Prior Authorization

Prior Authorization Required — Reference Clinical Criteria & Codes

Prior authorization is required. When requesting prior authorization, providers must reference the appropriate clinical criteria document number (ING-CC-0006) and submit the related HCPCS/CPT code(s). Requests that do not cite the clinical criteria document number and matching code(s) may be delayed or denied.

Include Clinical Criteria Document Number: ING-CC-0006 on the auth request
Include all applicable HCPCS/CPT codes (e.g., J7322, J7323, J7324, J7328, J7329)
Failure to map codes to the listed clinical criteria document number risks claim denial

Documentation Required

Coding → Clinical Criteria Mapping Required

Coding-document mapping is required. Claims and authorization requests must map each submitted HCPCS/CPT code to the corresponding ING-CC clinical criteria document number. Claims submitted without this mapping or with inconsistent code-to-document references are subject to denial.

Map each HCPCS/CPT code on the claim to ING-CC-0006
Ensure code descriptions match the clinical criteria drug list (e.g., hyaluronan injections / Durolane, Euflexxa, etc.)
Verify authorizations include both the ING-CC number and the exact codes billed

Note

Clinical Criteria & Code Reference — ING-CC-0006

When preparing prior authorization or billing, providers must reference the clinical criteria document and submit the exact HCPCS/CPT codes that correspond to the drug or service. For the Hyaluronan Injections criteria, use ING-CC-0006 and the associated J‑codes.

Auth and claim must reference ING-CC-0006 when billing hyaluronan injections
Submit the precise J-code(s) that reflect the drug product administered
If using unlisted or miscellaneous J-codes (e.g., J3490/J3590), include clinical justification and map to the ING-CC document

Step Therapy

Group Mapping & Potential Step Therapy — Check ING-CC Rules

Group mappings in the clinical criteria may imply step-therapy or multiple-agent mapping requirements. Review the ING-CC document for any group or agent sequencing rules before submitting an authorization or claim.

Check ING-CC-0006 for any step-therapy, prior-agent, or trial requirements
If multiple agents are listed in a group, document prior therapies or rationale per the clinical criteria
Failure to follow group/step requirements may result in authorization denial

Step Therapy / Grouped Drug Rules

ING-CC document	Representative mapped drugs / groups	Mapped HCPCS/CPT codes	Notes
ING-CC-0044	Exondys 51 (eteplirsen) mapped to multiple agents and groups (examples include Increlex [mecasermin]; Zinplava [bezlotoxumab]; Trogarzo [ibalizumab]; Spinraza [nusinersen]; Radicava [edaravone]; monoclonal antibodies to IL-23 [Ilumya, Tremfya]; enzyme replacement therapy for Gaucher disease including Cerezyme, Elelyso, Vpriv)	J1428 mapped variably to J2170, J0565, J1746, J2326, J1301, J1628, J3245 and others per entry	Multiple DRUG.* entries show a single ING-CC (0044) used to group Exondys 51 with many distinct products; specific HCPCS crosswalks differ by listed agent and are shown per DRUG entry
ING-CC-0045 / ING-CC-0046 / ING-CC-0047 / ING-CC-0048 / ING-CC-0049 / ING-CC-0050 / ING-CC-0051 (related mappings)	Examples of specific mappings from the Exondys 51 group to other products (see individual DRUG entries): Increlex; Zinplava; Trogarzo; Spinraza; Radicava; various IL-23 monoclonal antibodies; enzyme replacement therapies	See per-drug J-code mappings in source (e.g., J2170, J0565, J1746, J2326, J1301, J1628, J3245)	The policy indexes multiple ING-CC numbers that are equated or related (ING-CC-0044 = ING-CC-0045 etc.), indicating grouped step/coverage linkage; step therapy or sequencing rules, when applicable, are defined within the referenced ING-CC documents

Document Purpose & Scope

This document serves as an administrative index of clinical criteria updates effective March 1, 2019. It pairs specialty pharmacy drugs and drug classes with the internal clinical criteria document numbers (for example, ING-CC-0006 for Hyaluronan injections) and the associated HCPCS/CPT codes to guide coverage and prior authorization mapping. The index itself provides mapping information only; the referenced ING-CC documents contain the detailed medical necessity criteria used to adjudicate requests.

Key Terms & Code Definitions

Clinical Criteria Document Number — internal identifier

Clinical Criteria Document NumberING-CC-0006 (example of internal identifier used to reference detailed coverage criteria)

Other ING-CC examples in indexING-CC-0007, ING-CC-0008, ING-CC-0009, ING-CC-0010, ING-CC-0011

PurposeUnique internal identifier that maps a drug or drug group to its detailed clinical coverage criteria document

HCPCS/CPT Codes — billing identifiers

Representative HCPCS codes (hyaluronan injections)J7322, J7323, J7324, J7328, J7329

Other HCPCS/CPT examples in indexJ0202, J3490, J3590, S0189

Use on claims and prior authorizationsHCPCS/CPT codes listed in the index must be provided with prior authorization requests and on claims to map services to the referenced ING-CC documents