MED.00142 Gene Therapy for Cerebral Adrenoleukodystrophy

This policy addresses elivaldogene autotemcel gene therapy for cerebral adrenoleukodystrophy (CALD). Anthem covers a one-time infusion when all criteria are met: early-stage CALD with elevated very long-chain fatty acids and a confirmed ABCD1 mutation, a CALD-specific Neurological Function Scale (NFS) score of 0–1, and active CNS demyelination on gadolinium-enhanced brain MRI with a Loes score of 0.5–9.0. It is investigational and not medically necessary when these criteria are not met, including for repeat infusions.

"A one-time infusion of elivaldogene autotemcel is consideredmedically necessarywhenallof the following criteria are met:"

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