Coverage Policies

Use the index below to search for coverage information on specific medical conditions.

Note: For Arkansas State or Public School employees, services subject to pre-authorization are managed by Active Health Management, as noted in their Summary Plan Description.

For coverage information on high tech imaging (MRI, CT, PET) and nuclear medicine, administered by Evicore, click here.

Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

If not specified in a QualChoice coverage policy (Benefit Interpretation), QualChoice follows care guidelines published by MCG Health.

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

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.


Reference

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.
This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.