J3387 — Injection, elivaldogene autotemcel, per treatment
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Key Coverage Criteria
- A one-time infusion of elivaldogene autotemcel is consideredmedically necessarywhenallof the following criteria are met:
- The individual is in the early stages of cerebral adrenoleukodystrophy (CALD), as confirmed by the following:Elevated very long chain fatty acid levels;andConfirmation of the presence of anABCD1genetic mutation;andCALD-specific Neurological Function Scale (NFS) score of 0 or 1;andActive central nervous system (CNS) disease with demyelinating lesions demonstrated on brain gadolinium-enhanced MRI with Loes score between 0.5 and 9.0 on the 34-point scale;and
- Elevated very long chain fatty acid levels;and
- Confirmation of the presence of anABCD1genetic mutation;and
- CALD-specific Neurological Function Scale (NFS) score of 0 or 1;and
- Active central nervous system (CNS) disease with demyelinating lesions demonstrated on brain gadolinium-enhanced MRI with Loes score between 0.5 and 9.0 on the 34-point scale;and
1 Active Policy
ANTHEM-MED.00142 — MED.00142 Gene Therapy for Cerebral Adrenoleukodystrophy
Related Codes
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