Anthem Blue Cross Connecticut MED.00144 Gene Therapy for Duchenne Muscular Dystrophy Form


Delandistrogene Moxeparvovec-rokl (ELEVIDYS) Infusion for Duchenne Muscular Dystrophy

Indications

(91349) Does the patient have a diagnosis of Duchenne muscular dystrophy (DMD) with a confirmed mutation in the DMD gene? 
(91350) Does the patient have no deletion in exon 8 or exon 9 in the DMD gene? 
(91351) Is the patient ambulatory? 
(91352) Is the patient's age between 4 and 5 years (at least 4 years 0 days and less than 6 years old)? 
(91353) Does the patient have Anti-AAVrh74 total binding antibody titers less than 1:400? 
(91354) Does the patient have an absence of active infection? 
(91355) Does the patient lack significant liver dysfunction or disease, not having preexisting liver impairment, chronic hepatic condition, nor acute liver disease (e.g., acute hepatic viral infection)? 

Effective Date

12/28/2023

Last Reviewed

08/10/2023

Original Document

  Reference



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:

  1. Diagnosis of Duchenne muscular dystrophy (DMD) with a confirmed mutation in the DMD gene; and
  2. No deletion in exon 8 or exon 9 in DMD gene; and
  3. Ambulatory; and
  4. Age 4 through 5 years (at least 4 years 0 days and less than 6 years old); and
  5. Anti-AAVrh74 total binding antibody titers less than 1:400; and
  6. Absence of active infection; and
  7. Absence of significant liver dysfunction or disease, defined as at least one of the following:
    1. Preexisting liver impairment; or
    2. Chronic hepatic condition; or
    3. 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.