Management of Hereditary Angioedema (HAE) with C1 Esterase Inhibitor, Human and Ecallantide

This policy covers use of C1 esterase inhibitor, human (e.g., Cinryze) and ecallantide for management of hereditary angioedema (HAE), including routine prophylaxis (Cinryze for patients ≥6 years) and treatment of acute HAE attacks (C1‑INH or ecallantide for patients ≥12 years). Coverage requires diagnostic confirmation (C4, C1‑INH protein and function; additional criteria or genetic confirmation for HAE with normal C1‑INH), adherence to FDA labeling or authoritative compendia dosing, administration by qualified personnel for products with anaphylaxis risk, and is subject to member benefit limits, quantity restrictions, and other policy exclusions.

"Therapies must be proven effective for the relevant diagnosis or procedure based on current peer-reviewed scientific literature."

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