MED.00144 Gene Therapy for Duchenne Muscular Dystrophy

This policy addresses delandistrogene moxeparvovec-rokl (ELEVIDYS) gene therapy for Duchenne muscular dystrophy. It is covered as medically necessary only as a one-time infusion for ambulatory patients aged 4 to <6 years (4–5 years) with a confirmed DMD gene mutation and no deletion in exon 8 or 9; all other use is considered investigational and not medically necessary.

"A one-time infusion ofdelandistrogene moxeparvovec-rokl (ELEVIDYS) is consideredmedically necessaryin individuals who meetallof the following criteria:"

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