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Firazyr® (Icatibant)Berinert®, Cinryze® (C1 Esterase Inhibitor Human)Kalbitor® (Ecallantide)
DESCRIPTIONHereditary angioedema is a disorder characterized by recurrent episodes of severe swelling (angioedema). The most common areas of the body to develop swelling are the limbs, face, intestinal tract, and airway. Minor trauma or stress may trigger an attack, but swelling often occurs without a known trigger. Episodes involving the intestinal tract cause severe abdominal pain, nausea, and vomiting. Swelling in the airway can restrict breathing and lead to life-threatening obstruction of the airway.
Symptoms of hereditary angioedema typically begin in childhood and worsen during puberty. On average, untreated individuals have an attack every 1 to 2 weeks, and most episodes last for about 3 to 4 days. The frequency and duration of attacks vary greatly among people with hereditary angioedema, even among people in the same family.
HAE is estimated to affect 1 in 50,000 people.
Icatibant (Firazyr®) is a bradykinin B2 receptor antagonist. Herediatary angoiedema is caused by an absence or dysfunction of C1-esterase-inhibitor, a key regulator of the cascade that leads to bradykinin production. Firazyr® inhibits bradykinin from binding the B2 receptor and thereby treats the clinical symptoms of an acute, episodic attack of HAE.
FDA APPROVED INDICATIONS
Icatibant (Firazyr®) is indicated for the treatment of acute attacks of hereditary angioedema in adults 18 years of age and older. Firazyr® is administered by subcutaneous injection.
C1 Esterase Inhibitor Human (Berinert®) is indicated for the treatment of acute abdominal, facial, or laryngeal attacks of hereditary angioedema in adult and adolescent patients. Berinert® is administered by IV injection.
C1 Esterase Inhibitor Human (Cinryze®) is indicated for routine prophylaxis against angioedema attacks in adolescent and adult patients with hereditary angioedema. Cinryze® is administered IV every three or four days.
Ecallantide (Kalbitor®) is indicated for treatment of acute attacks of hereditary angioedema in patients 16 years of age and older. Kalbitor® is administered subcutaneously by a healthcare professional with appropriate medical support.
Generic Name: Icatibant
Generic Name: C1 Esterase Inhibitor Human
Generic Name: C1 Esterase Inhibitor Human
Generic Name: Ecallantide
POLICYPrior authorization is required for Firazyr®.
Icatibant (Firazyr®) is considered medically necessary for the treatment of acute attacks of hereditary angioedema in adults 18 years of age and older. Only three doses of Firazyr® are allowed per fill.
Berinert®, Cinryze®, and Kalbitor® should be administered under the supervision of a healthcare professional; therefore, these medications are not appropriate for use in the home care setting and are not prior authorized.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Nervous/Mental Conditions, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
POLICY HISTORY04/01/2012: New policy added.
01/07/2013: Added the following new 2013 CPT code to the Code Reference section: J1744.
04/02/2014: Added the generic name for each brand name in the policy subtitle. Second policy statement revised to remove “only” from the statement. It previously stated that Berinert®, Cinryze®, and Kalbitor® should only be administered under the supervision of a healthcare professional; therefore, these medications are not appropriate for use in the home care setting and are not prior authorized.
08/28/2015: Medical policy revised to add ICD-10 codes. Removed HCPCS code J3590 from the Covered Codes table.
05/26/2016: Policy number L.5.01.434 added. Policy Guidelines updated to add medically necessary and investigative definitions.
11/01/2016: Approved by Pharmacy & Therapeutics (P&T) Committee.
SOURCE(S)US National Library of Medicine
Firazyr® Prescribing Information
Kalbitor® Prescribing Information
Cinryze® Prescribing Information
Berinert® Prescribing Information
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.
This may not be a comprehensive list of procedure codes applicable to this policy.