Independent Health Medical Pharmacy Claims Edit Policies
For the following policies, Independent Health applies pre-payment claims edits using diagnosis and maximum unit criteria. Medical Necessity criteria contained in these policies does not apply.
Asparlas
(calaspargase pegol-mknl)
Botox
(onabotulinumtoxinA)
Independent Health applies pre-payment claims edits using diagnosis codes found in the CMS Local Coverage Article A52848 Billing and Coding: Botulinum Toxins.
Maximum 400 units every 84 days.
Doxorubicin liposomal
Doxil
Lipodox
Eloxatin
(oxaliplatin)
Emend IV
(fosaprepitant)
Erwinaze
(asparaginase)
Firmagon
(degarelix)
Fosaprepitant
(fosaprepitant)
Gemcitabine
Gemzar
Gemcitabine (Accord)
Infugem
(gemcitabine)
Injectafer
(injection, ferric carboxymaltose)
Oncaspar
(pegaspargase)
Rylaze
(asparaginase Erwinia chrysanthemi (recombinant)‐rywn)
Xeomin
(incobotulinumtoxinA)
Independent Health applies pre-payment claims edits using diagnosis codes found in the CMS Local Coverage Article A52848 Billing and Coding: Botulinum Toxins.
Maximum 400 units every 84 days.