Medical Policy

Effective Date:07/01/2012 Title:Ampyra (Dalfampridine)
Revision Date:02/01/2019 Document:BI368:00
CPT Code(s):None
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Dalfampridine ER requires prior authorization. Brand name Ampyra is not covered.

2)    Dalfampridine ER is used to improve walking in patients with multiple sclerosis.

Medical Statement

Dalfampridine ER is considered medically necessary for patients when all of the following criteria are met.  Initial approval, if granted, will be for 2 months.

1)    Patient has diagnosis of multiple sclerosis (G35).

2)    Patient is ambulatory and able to complete the 25-foot walk test within 8-45 seconds.

3)    Patient does not have a history of seizures. (no dx of G40.00-G40.919, Z86.69)

4)    Patient has normal renal function (ClCr > 50ml/min).

 

Continuation of therapy requests will be approved for 6 months.  Patient must demonstrate a 20% improvement from baseline in timed walking speed (25-foot walk test).

 

Limits

Dalfampridine is limited to a maximum of 60 tablets per month.

Reference

1)    Ampyra Product Information.  Accorda Therapeutics, Inc.  2010

2)    Goodman AD, Brown TR, Krup LB, et al.  Sustained release oral fampridine in multiple sclerosis.  Lancet 2009; 373:732-738.

Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.