HumanaCommercial Clinical Policy

Noninvasive Tests for Hepatic Fibrosis Form

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ultrasound transient elastography (eg, FibroScan)

Notes: Please refer to the specific pharmacy coverage policies for Hemgenix and RoctavianTM for additional information regarding their use.

Indications

(94216) Has the patient been diagnosed with chronic HCV evidenced by either quantitative tests (HCV RNA viral load) and/or qualitative tests (HCV antibody positive serum serology)? 
(94217) Has the patient been diagnosed with chronic liver disease as evidenced by sustained elevation of liver function tests (LTFs) for greater than 6 months? 
(94218) Is ultrasound transient elastography required prior to the use of Hemgenix (etranacogene dezaparvovec-drib) for treatment of Hemophilia B? 
(94219) Is ultrasound transient elastography required prior to the use of RoctavianTM (valoctocogene roxaparvovec-rvox) for the treatment of Hemophilia A? 
(94220) Has a liver biopsy not been performed on the patient within the previous 6 months? 

YesNoN/A
YesNoN/A
YesNoN/A

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Effective Date

09/28/2023

Last Reviewed

NA

Original Document

  Reference



Noninvasive Tests for Hepatic Fibrosis

Medical Coverage Policy

Effective Date: 09/28/2023
Revision Date: 09/28/2023
Review Date: 02/02/2023
Policy Number: HUM-0529-015
Page: 1 of 18
Change Summary: Updated Coverage Determination

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

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