BlueCross BlueShield of Tennessee Medical Policy Manual

Epoprostenol for Continuous Intravenous Infusion (Flolan®/ Veletri®)  

IMPORTANT REMINDER

We develop Medical Policies to provide guidance to Members and Providers.  This Medical Policy relates only to the services or supplies described in it.  The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy.  For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed.  If there is a conflict between the Medical Policy and a health plan or government program (e.g., TennCare), the express terms of the health plan or government program will govern.

POLICY

                   I.    INDICATIONS

The indications below including FDA-approved indications and compendial uses are considered a covered benefit provided that all the approval criteria are met and the member has no exclusions to the prescribed therapy.

FDA-Approved Indication

Flolan/Veletri/epoprostenol is indicated for the treatment of pulmonary arterial hypertension (PAH) (World Health Organization [WHO] Group I) to improve exercise capacity. Studies establishing effectiveness included predominantly patients with New York Heart Association (NYHA) Functional Class III-IV symptoms and etiologies of idiopathic or heritable PAH or PAH associated with connective tissue diseases.

All other indications are considered experimental/investigational and not medically necessary.

         II.    PRESCRIBER SPECIALTIES

This medication must be prescribed by or in consultation with a pulmonologist or cardiologist.

       III.    CRITERIA FOR INITIAL APPROVAL

Pulmonary Arterial Hypertension (PAH)

Authorization of 12 months may be granted for treatment of PAH when ALL of the following criteria are met:

A.    Member has PAH defined as WHO Group 1 class of pulmonary hypertension (refer to Appendix).

B.    PAH was confirmed by either criterion (1) or criterion (2) below: 

1.     Pretreatment right heart catheterization with all of the following results:  

i.      Mean pulmonary arterial pressure (mPAP) > 20 mmHg

ii.     Pulmonary capillary wedge pressure (PCWP) ≤ 15 mmHg

iii.    Pulmonary vascular resistance (PVR) ≥ 3 Wood units in adult patients or pulmonary vascular resistance index (PVRI) ≥ 3 Wood units x m² in pediatric patients

2.     For infants less than one year of age, PAH was confirmed by Doppler echocardiogram if right heart catheterization cannot be performed.

       IV.    CONTINUATION OF THERAPY  

Authorization of 12 months may be granted for members with an indication listed in Section III who are currently receiving the requested medication through a paid pharmacy or medical benefit, and who are experiencing benefit from therapy as evidenced by disease stability or disease improvement.

        V.    APPENDIX

WHO Classification of Pulmonary Hypertension (PH)

1 Pulmonary arterial hypertension PAH

1.1 Idiopathic (PAH)

1.2 Heritable PAH
1.3 Drug- and toxin-induced PAH

1.4. PAH associated with:

1.4.1 Connective tissue diseases

1.4.2 Human immunodeficiency virus (HIV) infection

1.4.3 Portal hypertension

1.4.4 Congenital heart diseases

1.4.5 Schistosomiasis

1.5 PAH long-term responders to calcium channel blockers

1.6 with overt features of venous/capillaries (pulmonary veno-occlusive disease [PVOD]/pulmonary capillary hemangiomatosis [PCH]) involvement

1.7 Persistent PH of the newborn syndrome

2 PH due to left heart disease
2.1 PH due to heart failure with preserved left ventricular ejection fraction (LVEF)

2.2 PH due to heart failure with reduced LVEF

2.3 Valvular heart disease

2.4 Congenital/acquired cardiovascular conditions leading to post-capillary PH

3 PH due to lung diseases and/or hypoxia
3.1 Obstructive lung disease

3.2 Restrictive lung disease

3.3 Other lung disease with mixed restrictive/obstructive pattern

3.4 Hypoxia without lung disease

3.5 Developmental lung disorders

4 PH due to pulmonary artery obstruction

4.1  Chronic thromboembolic PH

4.2  Other pulmonary artery obstructions

4.2.1      Sarcoma (high or intermediate grade) or angiosarcoma

4.2.2      Other malignant tumors

Renal carcinoma

Uterine carcinoma

Germ cell tumours of the testis

Other tumours

4.2.3      Non-malignant tumours

Uterine leiomyoma

4.2.4      Arteritis without connective tissue disease

4.2.5      Congenital pulmonary artery stenosis

4.2.6      Parasites

Hydatidosis

5 PH with unclear and/or multifactorial mechanisms

5.1 Hematologic disorders: Chronic hemolytic anemia, myeloproliferative disorders

5.2 Systemic and metabolic disorders: Pulmonary Langerhans cell histiocytosis, Gaucher disease, glycogen storage disease, neurofibromatosis, sarcoidosis

5.3 Others: chronic renal failure with or without hemodialysis, fibrosing mediastinitis

5.4  Complex congenital heart disease

APPLICABLE TENNESSEE STATE MANDATE REQUIREMENTS

BlueCross BlueShield of Tennessee’s Medical Policy complies with Tennessee Code Annotated Section 56-7-2352 regarding coverage of off-label indications of Food and Drug Administration (FDA) approved drugs when the off-label use is recognized in one of the statutorily recognized standard reference compendia or in the published peer-reviewed medical literature.

ADDITIONAL INFORMATION  

For appropriate chemotherapy regimens, dosage information, contraindications, precautions, warnings, and monitoring information, please refer to one of the standard reference compendia (e.g., the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) published by the National Comprehensive Cancer Network®, Drugdex Evaluations of Micromedex Solutions at Truven Health, or The American Hospital Formulary Service Drug Information).

REFERENCES 

1. Flolan [package insert]. Research Triangle Park, NC: GlaxoSmithKline; October 2023.
2. Veletri [package insert]. Titusville, NJ: Actelion Pharmaceuticals US, Inc.; July 2022.
3. Epoprostenol [package insert]. Durham, NC: GlaxoSmithKline October 2023.
4. McLaughlin VV, Archer SL, Badesch DB, et al. ACCF/AHA 2009 expert consensus document on pulmonary hypertension a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents and the American Heart Association developed in collaboration with the American College of Chest Physicians; American Thoracic Society, Inc.; and the Pulmonary Hypertension Association. J Am Coll Cardiol. 2009;53(17):1573-1619.
5. Badesch DB, Champion HC, Gomez-Sanchez MA, et al. Diagnosis and assessment of pulmonary arterial hypertension. J Am Coll Cardiol. 2009;54:S55-S66.
6. Taichman DB, Ornelas J, Chung L, et al. Pharmacologic therapy for pulmonary arterial hypertension in adults. CHEST guideline and expert panel report. Chest. 2014;46(2):449-475.
7. Abman, SH, Hansmann G, Archer SL, et al. Pediatric pulmonary hypertension: guidelines from the American Heart Association and American Thoracic Society. Circulation. 2015;132(21):2037-99.
8. Klinger, JR., Elliott, CG, Levine, DJ, et al. Therapy for pulmonary arterial hypertension in adults: update of the CHEST guidelines and expert panel report. Chest. 2019:155(3): 565-586.
9. Galie, N., McLaughlin, VV, Rubin, LJ, Simonneau, G. An overview of the 6th World Symposium on Pulmonary Hypertension. Eur Respir J 2019; 53(1):1802148; DOI: 10.1183/13993003.02148-2018
10. Simonneau G, Montani D, Celermajer DS, et al. Haemodynamic definitions and updated clinical classification of pulmonary hypertension. Eur Respir J 2019;53:1801913. doi:10.1183/13993003.01913-2018.

ORIGINAL EFFECTIVE DATE: 5/7/2018

MOST RECENT REVIEW DATE: 12/10/2024

ID_CHS

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

This document has been classified as public information.