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DESCRIPTIONACTH gel (repository corticotropin injection) is a purified sterile preparation of adrenocorticotropic hormone (ACTH) in gelatin to provide a prolonged release after intramuscular or subcutaneous injection. ACTH works by stimulating the adrenal cortex to produce cortisol, corticosterone, and a number of other hormones.
According to the 2010 product information (product labeling), repository corticotropin injection may be used in the treatment of the following conditions:
Contraindications for use of this agent include scleroderma, osteoporosis, systemic fungal infections, ocular herpes simplex, recent surgery, history of or the presence of a peptic ulcer, congestive heart failure, hypertension, or sensitivity to proteins of porcine origin.
West Syndrome/Infantile Spasms
In December 2008, Questcor resubmitted a supplemental new drug application (sNDA) for H.P. Acthar gel (repository corticotrophin) injection to the FDA for treating infantile spasms. Approval was granted in October 2010.
Alternative Treatments for Infantile Spasms
POLICYRepository corticotropin injection may be considered medically necessary for treatment of infantile spasms.
Repository corticotropin injection is considered not medically necessary for use in diagnostic testing of adrenocortical function.
Use of repository corticotropin injection is considered not medically necessary as treatment of corticosteroid-responsive conditions, unless there are medical contraindications or intolerance to corticosteroids that are not also expected to occur with use of repository corticotropin injection.
Except as noted above, use of repository corticotropin injection is considered investigational for conditions that are not responsive to corticosteroid therapy including, but not limited to, use in tobacco cessation, acute gout, and childhood epilepsy.
POLICY EXCEPTIONSFederal Employee Program (FEP) may dictate that all FDA-approved devices, drugs or biologics may not be considered investigational and thus these devices may be assessed only on the basis of their medical necessity.
POLICY GUIDELINESInvestigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY2/21/2008: Policy added
3/27/2008: Reviewed and approved by the Medical Policy Advisory Committee (MPAC)
06/22/2010: Policy title changed from “ACTH gel” to “ACTH Gel (Repository Corticotropin Injection). Terminology updated throughout policy. Policy statement regarding repository corticotropin injection use in diagnostic testing of adrenocortical function changed from medically necessary to not medically necessary. Deleted the following ICD-9 codes from the Covered Codes table due to the policy statement change: 255.0, 255.10, 255.11, 255.12, 255.13, 255.14, 255.2, 255.3, 255.41, 255.42, 255.5, 255.6, 255.8, 255.9. Policy statement updated regarding corticosteroid-responsive conditions and to add acute gout and childhood epilepsy as investigational conditions. Policy guidelines updated with supporting explanations. FEP verbiage added to the Policy Exceptions section. Added CPT code 96372.
08/11/2011: Policy description and guidelines updated. Policy statement unchanged.
SOURCE(S)Blue Cross & Blue Shield Association Policy # 5.01.17
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.