| MP 2.01.13 | Human Antihemophilic Factor (AHF) | |
| Medical Policy | ||
| Section Medicine |
Original Policy Date 12/1/95 |
Last Review Status/Date No routine review scheduled/1:2003 |
| Issue 1:2003 |
Return to Medical Policy Index |
Disclaimer
Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract. Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage. Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.
Description
Human antihemophilic factor (AHF, Factor VIII) maintenance therapy is used as an alternative to “on-demand” therapy to reduce the incidence of bleeding episodes and resultant joint damage in patients who have severe hemophilia A (AHF activity less than 1% of normal). In on-demand therapy, human AHF concentrate is infused when trauma or joint pain is observed consistent with internal bleeding.
During maintenance therapy, also known as prophylactic therapy, human AHF concentrate is infused on a weekly schedule with the goal of maintaining AHF activity at a level sufficient to prevent bleeding (generally AHF activity greater than 1%).
Policy
The use of human antihemophilic factor (AHF) maintenance therapy for severe hemophilia A (i.e., AHF activity less than 1% of normal) is medically necessary to maintain the trough AHF activity at greater than 1%.
Policy Guidelines
No applicable information
Benefit Application
BlueCard/National Account Issues
Human antihemophilic factor is a blood derivative applicable for processing under the Blood benefit if defined to include blood derivatives; otherwise, it may be processed under Prescription Drugs when utilized and defined as drugs.
Rationale
A search of the literature was completed through the MEDLINE database for the period of January 1992 through May 1995. The search strategy focused on references containing the following Medical Subject Headings:
– Factor VIII
– Hemophilia A
– Prophylaxis
Research was limited to English-language journals on humans.
See also:
TEC Assessments 1995: Tab 8
Current Contents
References:
|
Codes |
Number |
Description |
| CPT | 90780 | IV infusion for therapy/diagnosis, administered by physician or under direct supervision of physician, up to one hour |
| 90781 | Each additional hour, up to 8 hours | |
| ICD-9 Procedure | 99.29 | Injection or infusion of other therapeutic or prophylactic substance |
| ICD-9 Diagnosis | 286.0 | Congenital Factor VIII disorder |
| HCPCS | J7190 | Factor VIII (human), per IU |
| J7191 | Factor VIII (porcine), per IU | |
| J7192 | Factor VIII (recombinant), per IU | |
| Type of Service | Medicine | |
| Place of Service | Inpatient Outpatient Home |
|
Index
AHF, Human
Factor VIII
Human AHF
Human Antihemophilic Factor
Policy History
| Date | Action | Reason |
| 12/01/95 | Add to Medicine section | New Policy |
| 04/15/02 | Replace Policy | Policy reviewed without literature review; new review date only |
| 04/29/03 | Replace Policy | Policy no longer scheduled for routine literature review. |
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