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Effective Date: 11/01/2018 Title: Crysvita
Revision Date: Document: BI582:00
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)    Crysvita (burosumab-twza) requires prior authorization.

2)  Crysvita is used to treat a rare form of hypophosphatemia.

Medical Statement

Crysvita (burosumab-twza) is considered medically necessary for patients who:

1)    Are 1 year of age or older AND

2)    Have a diagnosis of X-linked hypophosphatemia (XLH),which is also known as X-linked dominant hypophosphatemic rickets or X-linked vitamin D-resistant rickets) AND

3)    Patient will discontinue any oral phosphate or active vitamin D analog supplementation at least one week prior to starting therapy with Crysvita AND

4)    Prescriber agrees to measure serum phosphorous level monthly for the first three (3) months of therapy and periodically throughout therapy, holding the dose if level above 5mg/dL AND

5)    Fasting serum phosphorous is not within or above the normal range for age at start of therapy AND

6)    Patient does not have severe renal impairment or end stage renal disease (ESRD), defined as eGFR < 30mL/min/1.73m2.


Reauthorization Criteria:

1)    Patient must have diagnosis of X-linked hypophosphatemia AND

2)    Prescriber agrees to measure serum phosphorous throughout therapy and hold the dose if level above 5mg/dL AND

3)    Patient does not have severe renal impairment or end stage renal disease (ESRD), defined as eGFR < 30mL/min/1.73m2.


1)    Crysvita Prescribing Information. Ultragenyx Pharmaceutical Inc. Novato, CA. April 2018.

2)    Clinical Pharmacology. Accessed online 8/17/2018.

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.
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