Anthem Blue Cross California Commercial Clinical Policy

Anthem Blue Cross California Ycanth (cantharidin) Form


Effective Date

01/01/2024

Last Reviewed

09/11/2023

Original Document

  Reference



Overview

This document addresses the use of Ycanth (cantharidin), approved by the Food and Drug Administration (FDA) for the topical treatment of molluscum contagiosum in adult and pediatric individuals 2 years of age and older. Ycanth should be administered by a healthcare professional. Ycanth is for topical use only and should not be applied near the eyes or mucosal tissues. Contact with the treatment area, including oral contact, should be avoided after Ycanth administration. Up to two applicators of Ycanth can be used during a treatment session and sessions can be repeated every 3 weeks as needed. The safety and effectiveness of more than 4 treatment sessions over the course of 12 weeks has not been established.

Clinical Criteria

When a drug is being reviewed for coverage under a member’s medical benefit plan or is otherwise subject to clinical review (including prior authorization), the following criteria will be used to determine whether the drug meets any applicable medical necessity requirements for the intended/prescribed purpose.

Ycanth (cantharidin)
  • Requests for Ycanth (cantharidin) may be approved if the following criteria are met:
    1. Individual is 2 years of age or older; AND
    2. Individual is using for the topical treatment molluscum contagiosum.
  • Requests for Ycanth (cantharidin) may not be approved for the following:
    1. Treatment of lesions in or near the eyes or mucosal tissues; OR
    2. Use in combination with another treatment modality (including but not limited to cryotherapy, curettage or podofilox); OR
    3. May not be approved when the above criteria are not met and for all other indications.

Approval Duration: 12 weeks per year

Quantity Limits

Ycanth (cantharidin) Quantity Limit
Ycanth (cantharidin) 0.7% topical solution
8 applicators per 12 weeks

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Unclassified drugs (when specified as [Ycanth] (cantharidin)
HCPCS
J3490
C9164
ICD-10 Diagnosis
All diagnoses pend

Document History

New: 9/11/2023
Want to learn more?