Gout - Medical Clinical Policy Bulletins

Coverage for the treatment of gout includes medically necessary services and diagnostic tests such as blood uric acid level measurements for members aged 18 and older with chronic gout. Key requirements for coverage of pegloticase (Krystexxa) include having at least two gout flares per year despite previous treatments, while also demonstrating clinical benefit during therapy. Limitations include a requirement for precertification, prohibiting use with oral urate-lowering therapies, and necessitating prior documentation of treatment failure for allopurinol or febuxostat.

"Treatment of gout is covered for medically necessary services following standard protocols."

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