Treatment for Duchenne Muscular Dystrophy

This policy addresses treatment of Duchenne muscular dystrophy (DMD), including genetic testing for dystrophin (DMD) variants, supportive care such as noninvasive ventilation, and FDA‑approved antisense oligonucleotides (e.g., eteplirsen for exon 51; golodirsen and viltolarsen for exon 53; casimersen for exon 45). Coverage is limited to patients with a confirmed DMD mutation amenable to the specific exon‑skipping therapy and to uses/dosing consistent with authoritative sources and the member’s benefit plan, and these antisense agents have accelerated approval and may be considered not medically necessary or experimental when clinical benefit has not been established (confirmatory trials lacking).

"Therapies covered when proven effective for the relevant diagnosis or procedure based on generally accepted standards of practice."

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