Payer PolicyActive
Defibrotide sodium (Defitelio)
EVICORE-MEDICAL_DRUG-B7CDD5C2
EviCore by Evernorth
Effective: January 1, 2019
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Defitelio (defibrotide sodium) is covered only for hepatic veno-occlusive disease (sinusoidal obstruction syndrome) with renal and/or pulmonary dysfunction following hematopoietic stem‑cell transplantation, with coverage limited to 60 days. Coverage excludes use with concomitant systemic anticoagulants or fibrinolytics and in patients with active bleeding, and requires documentation of diagnosis and organ dysfunction, ongoing monitoring for bleeding and allergic reactions, and withholding/discontinuation for significant bleeding or severe allergic reaction.
Coverage Criteria Preview
Key requirements from the full policy
"Treatment of hepatic veno-occlusive disease (sinusoidal obstruction syndrome) with renal or pulmonary dysfunction following hematopoietic stem-cell transplantation (FDA-approved indication)."
Sign up to see full coverage criteria, indications, and limitations.