Anthem Blue Cross CaliforniaCommercial Clinical Policy

Duopa (carbidopa and levodopa enteral suspension) Form

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Duopa (carbidopa and levodopa enteral suspension) Initial Therapy

Indications

(167757) Does the patient have a diagnosis of advanced Parkinson's disease with complicated motor fluctuations? 
(167758) Is the patient using Duopa via a percutaneous endoscopic gastrostomy with jejunal tube (PEG-J) or naso-jejunal tube? 
(167759) Is there documentation that the patient's symptoms have not been adequately controlled with optimal medical therapy including oral levodopa-carbidopa? 
(167760) Has the patient used dopamine agonists? 
(167761) Has the patient used one agent from the following classes: COMT inhibitor, MAO B inhibitor, or Adenosine receptor antagonist (Nourianz)? 

YesNoN/A
YesNoN/A
YesNoN/A

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Effective Date

09/18/2023

Last Reviewed

08/18/2023

Original Document

  Reference



Overview

This document addresses the use of Duopa (carbidopa and levodopa enteral suspension) infusion for the treatment of late-stage Parkinson’s disease (PD) in individuals who have poor function (as defined by more “off” periods and fluctuations between “on/off” periods and/or dyskinesias) despite optimal medical therapy.

Parkinson's Disease (PD) Overview

PD is a progressive neurodegenerative disorder associated with motor complications such as tremor, bradykinesia, and rigidity. The decision to initiate pharmacologic therapy for the management of symptoms associated with PD is determined by the degree to which the individual is functionally impaired and influenced by a variety of individual and medication-related factors. Treatment is individualized and combination therapy is often employed to manage symptoms and reduce “off” episodes (refers to “end-of-dose wearing off” and unpredictable “on/off” episodes).

Coding

  • HCPCS
    • J7340
    • Carbidopa 5 mg/levodopa 20 mg enteral suspension, 100 ml

ICD-10 Diagnosis

  • G20
    • Parkinson's disease

Document History

Revised: 08/18/2023