Medicare Advantage

The Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member's medical needs and condition.

MEDICALLY NECESSARY

INITIAL THERAPY   

Secukinumab (Cosentyx) for intravenous infusion is considered medically necessary and, therefore, covered for the following indications when, for each individual indication, all of the associated criteria are met:

Psoriatic Arthritis (PsA)

Secukinumab (Cosentyx) for intravenous infusion may be covered as monotherapy or concomitantly with nonbiologic disease-modifying antirheumatic drugs (DMARDs) when all of the following criteria are met:

• Active or latent tuberculosis (TB) has been ruled out.
• The individual has had an inadequate response after at least 3 months of one or more DMARDs (e.g., methotrexate, hydroxychloroquine, leflunomide, azathioprine, sulfasalazine), or the use of all DMARDs is contraindicated in the individual.
• The individual is 18 years of age or older.
• Secukinumab (Cosentyx) will not be used in combination with other biologic DMARDs or Janus kinase inhibitor (JAK) inhibitors.

Ankylosing Spondylitis (AS)

• The individual is at least 18 years old.
• Documentation of failure, contraindication to, or intolerance of either of the following:
• At least a 4-week trial of two nonsteroidal anti-inflammatory drugs (NSAIDs) at maximum recommended or tolerated anti-inflammatory dose
• At least a 3-month trial of one DMARD (e.g., sulfasalazine, methotrexate, hydroxychloroquine)
• Active or TB has been ruled out.

Axial spondyloarthritis (nonradiographic)

• When all of the following criteria are met:
• Individual is at least 18 years of age
• Documentation of evidence of active disease (increasing inflammation, pain, disability, and decreased function)
• Documentation of an adequate therapeutic trial* of at least two NSAIDs that have failed to control symptoms

• If the above criteria are not met, there must be documentation, both of very severe disease and that the clinician considers infliximab or related biosimilars the best initial drug of choice with appropriate justification (severe pain, disability, and inability to perform activities of daily living [ADLs], or severe impact on quality of life).​​

CONTINUATION THERAPY

Secukinumab (Cosentyx) for intravenous infusion is considered medically necessary and, therefore, covered for continuation therapy when the individual meets all of the following criteria: 

• The individual has met the medical necessity criteria for initial therapy.    
• There is documentation of a positive clinical response or stabilization to therapy (e.g., improvement in total active [swollen and tender] joint count from baseline, improvement in  symptoms [e.g., pain, stiffness, inflammation, body surface area] from baseline).

EXPERIMENTAL/INVESTIGATIONAL

All other uses for secukinumab (Cosentyx) for intravenous use are considered experimental/investigational and, therefore, not covered unless the indication is supported as an accepted off-label use, as defined in the Company medical policy on off-label coverage for prescription drugs and biologics. 

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.