S0106, Bupropion hcl sustained release tablet, 150 mg, per bottle of 60 tablets
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
Documentation Required
- No explicit documentation requirements are stated in this excerpt. The policy text references commonly used clinical assessments and tests frequently used in trials and practice, which are typically documented when evaluating treatment effect or safety, including:
- Baseline and follow-up Unified Huntington's Disease Rating Scale (UHDRS) motor and chorea subscores (used as primary motor/chorea outcome measures in multiple studies).
- Cognitive assessments: Mini-Mental State Examination (MMSE), Alzheimer Disease Assessment Scale-cognitive subscale (ADAS-cog), Symbol Digit Modalities Test (SDMT), Stroop tests, verbal fluency tests (used as trial endpoints).
- CSF sampling for measurement of mutant huntingtin concentration (as used in HTTRx trials) and/or neurofilament light (NF-L) measurement in plasma/CSF (investigational biomarkers described).
Key Coverage Criteria
- None explicitly stated. This Clinical Policy Bulletin addresses selected interventions for Huntington's disease and identifies numerous interventions and tests that Aetna considers experimental and investigational (see Limitations).
- If HD chorea requires treatment, clinicians should prescribe tetrabenazine (up to 100 mg/day), amantadine (300 to 400 mg/day), or riluzole (200 mg/day) (Level B).
- Clinicians may also prescribe nabilone for modest decreases (1- to less than 2-point changes on the UHDRS chorea score) in HD chorea (Level C), but information is insufficient to recommend long-term use.
- Deutetrabenazine (a deuterated form of tetrabenazine) was recently approved for the treatment of chorea in HD; administered twice-daily up to a maximum daily dose of 48 mg.
- Electroconvulsive therapy (ECT) has been reported to be well-tolerated and to produce improvement in psychiatric and behavioral symptoms (depression, psychosis) in HD in a small case series.
- Percutaneous endoscopic gastrostomy (PEG) tube placement in advanced HD: one retrospective review reported increased length of life (in deceased patients insertion of a PEG tube increased length of life with HD by 3.6 years), although nutritional and other outcomes were mixed.
1 Active Policy
AETNA-CPB-0614, Huntington's Disease
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