This version of the policy will become effective 06/03/2019.
This policy has been updated to be consistent with the US Food and Drug Administration (FDA) labeling, including age requirements. Dosing and frequency requirements were added for all the agents. Laboratory and/or genetic testing requirements were added to all diagnoses.
E76.01 Hurler's syndrome
E76.02 Hurler-Scheie syndrome
E76.03 Scheie's syndrome
E76.1 Mucopolysaccharidosis, type II
E76.210 Morquio A mucopolysaccharidoses
E76.29 Other mucopolysaccharidoses
J1322 Injection, elosulfase alfa, 1 mg
J1458 Injection, galsulfase, 1 mg
J1743 Injection, idursulfase, 1 mg
J1931 Injection, laronidase, 0.1 mg
J3397 Injection, vestronidase alfa-vjbk, 1 mg
Policy: MA08.012b:Off-label Coverage for Prescription Drugs and/or Biologics