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Medical & Coding Policies
Provider Network Application
Out-of-State & Non-Network
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DESCRIPTIONKalydeco is classified as a cystic fibrosis transmembrane conductance regulator (CFTR) potentiator. The CFTR protein is a chloride channel present at the surface of epithelial cells in multiple organs. Kalydeco facilitates increased chloride transport by potentiating the gating of the G551D-CFTR protein. Kalydeco is the first available treatment for cystic fibrosis (CF) that targets the defective CFTR protein, which is the underlying cause of CF.FDA APPROVED INDICATIONS IDENTIFICATION
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POLICYPrior authorization is required.Kalydeco® is considered medically necessary for the treatment of cystic fibrosis in patients age 6 years and older who have a G551D mutation in the CFTR gene detected by an FDA-cleared CF mutation test. A maximum of 60 tablets per month will be approved. After six months of therapy, documentation of improvement in FEV1, symptoms, and stabilization of disease is required for continued treatment.
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POLICY EXCEPTIONSNone
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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.
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POLICY HISTORY07/26/2012: New policy added.
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SOURCE(S)Kalydeco® Prescribing Information
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CODE REFERENCEThis is not intended to be a comprehensive list of codes. Some covered procedure codes have multiple descriptions.The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document. Covered Codes
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