Rethymic (allogeneic processed thymus tissue-agdc) - MEDICAID - VIRGINIA

This policy covers Rethymic (allogeneic processed thymus tissue‑agdc) for immune reconstitution as the FDA‑approved curative treatment for congenital athymia. Coverage is limited to pediatric patients (≤17 years) with confirmed congenital athymia (e.g., flow cytometry and SCID testing showing circulating CD3+ <50/mm3 and CD45RA+CD62L+ naïve T cells <50/mm3 or <5% of T cells) who are surgical candidates, have no contraindications, are eligible for a single lifetime dose, and whose requests require medical director review (and referral to the Corporate Transplant Department) and may be subject to plan-specific limits.

"Clinical policy is not intended to preempt the judgment of the reviewing medical director or dictate to health care providers how to practice medicine."

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