Anthem Blue Cross Connecticut MED.00144 Gene Therapy for Duchenne Muscular Dystrophy Form
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This document addresses gene therapy for Duchenne muscular dystrophy (DMD), a rare and serious genetic disease affecting muscle strength and movement. Gene therapy is being proposed as a one-time treatment to significantly lessen the severity of DMD. At this time, one gene therapy has been approved by the Food and Drug Administration (FDA) to treat DMD: delandistrogene moxeparvovec-rokl (ELEVIDYS), an adeno-associated virus vector-based gene therapy.
Note: Please refer to the applicable clinical pharmacy criteria used by the Plan for information regarding disease-modifying treatments for DMD; for example: casimersen (Amondys 45), viltolarsen (Viltepso), and golodirsen (Vyondys 53).
Position Statement
Medically Necessary:
A one-time infusion of delandistrogene moxeparvovec-rokl (ELEVIDYS) is considered medically necessary in individuals who meet all of the following criteria:
- Diagnosis of Duchenne muscular dystrophy (DMD) with a confirmed mutation in the DMD gene; and
- No deletion in exon 8 or exon 9 in DMD gene; and
- Ambulatory; and
- Age 4 through 5 years (at least 4 years 0 days and less than 6 years old); and
- Anti-AAVrh74 total binding antibody titers less than 1:400; and
- Absence of active infection; and
- Absence of significant liver dysfunction or disease, defined as at least one of the following:
- Preexisting liver impairment; or
- Chronic hepatic condition; or
- Acute liver disease (e.g., acute hepatic viral infection).
Investigational and Not Medically Necessary:
Delandistrogene moxeparvovec-rokl is considered investigational and not medically necessary when the criteria above are not met.