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S.5.01.542
Amvuttra (vutrisiran)
Please perform a search of the State Health Plan Medical Drug Formulary for drugs administered and billed through the medical setting.
Hereditary transthyretin-mediated amyloidosis (hATTR) is a rare, autosomal dominant, progressive, and fatal multi-system illness characterized by the extracellular deposition of misfolded transthyretin (TTR) protein. Though the rate at which hATTR amyloidosis progresses is unpredictable, these deposits cause significant neurological problems, functional limitations, and disability over time. These presentations include a predominantly neurologic phenotype, formerly known as familial amyloid polyneuropathy (FAP), and a predominantly cardiac phenotype, formerly known as familial cardiomyopathy, but the majority of cases express both neurologic and cardiac manifestations.
Amvuttra (vutrisiran) is indicated for the treatment of the cardiomyopathy of wild-type or hereditary transthyretin-mediated amyloidosis (ATTR-CM) in adults to reduce cardiovascular mortality, cardiovascular hospitalizations and urgent heart failure visits and for the treatment of the polyneuropathy of hereditary transthyretin-mediated amyloidosis (hATTR-PN) in adults.
Related Medical Policies -
Amvuttra is considered not medically necessary as there are other formulary alternatives covered by the Plan for the treatment of ATTR-CM.
Services related to delivery and/or administration of a medication determined to be not medically necessary will also be considered not medically necessary.
None
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 Mental Health Disorders, 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 medical necessity, “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.
12/02/2025: Policy reviewed and approved by the Pharmacy & Therapeutics (P&T) Committee. New policy added.
Amvuttra prescribing information. Alnylam Pharmaceuticals, Inc. March 2025. Last accessed September 2025.
This may not be a comprehensive list of procedure codes applicable to this policy.
Not Medically Necessary Codes
Code Number | Description |
CPT-4 | |
HCPCS | |
J0225 | Injection, vutrisiran, 1 mg |
ICD-10 Procedure | |
ICD-10 Diagnosis |
CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
