Hereditary Angioedema - BMC HealthNet Plan

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Clinical Background Information and References:1. Zuraw B. Clinical Practice: Hereditary angioedema. N Engl J Med. 2008;359(10):1027-36.2. Bowen T, et al. 2010 International Consensus Algorithm for the Diagnosis,Therapy, and Management of Hereditary Angioedema. Allergy Asthma &Clinical Immunology. 2010; 6:24. Available at:http://www.aacijournal.com/content/pdf/1710-1492-6-24.pdf.3. Atkinson JP, Ciardi M, Sheffer AL. Prevention of attacks in hereditaryangioedema. UptoDate. Last updated September 20, 2012., Accessed February2013. Available from http://www.uptodate.com. .4. Atkinson JP, Ciardi M, Sheffer AL. Treatment of acute attacks in hereditaryangioedema. UptoDate. Last updated October 24, 2012., Accessed February 2013.Available from http://www.uptodate.com.5. Cinryze ® [package insert]. Exton (PA): ViroPharma Biologics, Inc.; July 2012.6. Berinert ® [package insert]. Kankakee (IL): CSL Behring LLC; July 2012.7. Kalbitor ® [package insert]. Burlington (MA): Dyax Corp.; February 2012.8. Firazyr ® [package insert]. Lexington (MA): Shire; August 2011.9. Sardana N, Craig TJ. Recent Advances in Management and Treatment ofHereditary Angioedema. Pediatrics. 2011;128:1173-1180.Appendix A: Quantity Limitations for Cinryze TMMedication NameQuantity LimitationCinryze TM 500 unit vials16 vials per 30 daysPolicy History:Effective Date: 09/10/2009Date of Review/Revision03/11/2010) – P&T Annual Review, criteria added for Berinert ® and Kalbitor ®03/10/2011 – P&T Annual Review, no changes required07/14/2011 – policy applied to Commercial03/08/2012 – P&T Annual Review, removed requirement of healthcare professionaladministration for Berinert ® , criteria added for Firazyr ®This guideline provides information on BMC HealthNet Plan clinical criteria and claims adjudication processing guidelines. Theuse of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement isbased on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Planpolicies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider.Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the mostrecent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accreditingorganization guidelines and requirements, including NCQA.This document is subject to further revision in response to additional terms and requirements imposed under the Integrated CareProgram, including the ICP contract.BMCHP refers to Boston Medical Center HealthNet Plan in Massachusetts and Well Sense Health Plan in New Hampshire.Boston Medical Center HealthNet Plan and Well Sense Health Plan are trade names used by Boston Medical Center Health Plan,Inc.6 of 7BMC HealthNet Plan – Hereditary Angioedema
Last Review Date: 03/14/2013 – P&T Annual Review, removed prophylaxisrequirements for initial approval of Berinert ® , Kalbitor ® and Firazyr ® , added requirementof prophylaxis to COT criteria for Berinert ® , Kalbitor ® and Firazyr ® , updated criteria forlong-term prophylaxisNext Review Date: 03/13/2014Approval DatesRegulatory Approval: N/AInternal Approval:Initial approval by Pharmacy & Therapeutics Committee – September 10, 2009Authorizing entityN/AIMPORTANT NOTE:‣ Not all services are covered for all products or employer groups. This medical policyexpresses the Plan's determination of whether certain services or supplies are medicallynecessary, experimental or investigational or cosmetic. The Plan has reached theseconclusions based upon the regulatory status of the technology and a review of clinicalstudies published in peer-reviewed medical literature. Even though this policy mayindicate that a particular service or supply is considered covered or not covered, thisconclusion is not based upon the terms of a member’s particular benefit plan. Eachbenefit plan contains its own specific provisions for coverage and exclusions. Not allservices that are determined to be medically necessary will necessarily be coveredservices under the terms of a member’s benefit plan. Members and their providers needto consult the applicable benefit plan document (e.g., Evidence of Coverage) todetermine if there are any exclusions or other benefit limitations applicable to this serviceor supply. If there is a discrepancy between this medical policy and the benefit plandocument, the provisions of the benefit plan document will govern. In addition, this policyand the benefit plan document are subject to applicable state and federal laws that maymandate coverage for certain services and supplies.‣ To the extent applicable, this Policy and/or Procedure applies to BMCHP subcontractorsand downstream entities, if any, providing services with respect to BMCHP’s IntegratedCare Program.This guideline provides information on BMC HealthNet Plan clinical criteria and claims adjudication processing guidelines. Theuse of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement isbased on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Planpolicies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider.Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the mostrecent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accreditingorganization guidelines and requirements, including NCQA.This document is subject to further revision in response to additional terms and requirements imposed under the Integrated CareProgram, including the ICP contract.BMCHP refers to Boston Medical Center HealthNet Plan in Massachusetts and Well Sense Health Plan in New Hampshire.Boston Medical Center HealthNet Plan and Well Sense Health Plan are trade names used by Boston Medical Center Health Plan,Inc.7 of 7BMC HealthNet Plan – Hereditary Angioedema
Page 1 and 2: BMCHP.ORG1-888-566-0008WELLSENSE.OR
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Hereditary Angioedema - BMC HealthNet Plan

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