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
Rivfloza is indicated to lower urinary oxalate levels in children 9 years of age and older and adults with primary hyperoxaluria type 1 (PH1) and relatively preserved kidney function, e.g., eGFR of greater than or equal to 30 mL/min/1.73 m2.
All other indications are considered experimental/investigational and not medically necessary.
II. DOCUMENTATION
Submission of the following information is necessary to initiate the prior authorization review:
A. Molecular genetic test results demonstrating a mutation in the alanine:glyoxylate aminotransferase (AGXT) gene or liver enzyme analysis results demonstrating absent or significantly reduced alanine:glyoxylate aminotransferase (AGT) activity.
B. Chart notes or medical records demonstrating a positive response to therapy (for continuation requests).
III. CRITERIA FOR INITIAL APPROVAL
Primary hyperoxaluria type 1 (PH1)
Authorization of 12 months may be granted for the treatment of primary hyperoxaluria type 1 (PH1) when all of the following criteria are met:
A. Member is 9 years of age or older.
B. Member has a diagnosis of PH1 confirmed by either of the following:
1. Molecular genetic test results demonstrating a mutation in the alanine:glyoxylate aminotransferase (AGXT) gene.
2. Liver enzyme analysis results demonstrating absent or significantly reduced alanine:glyoxylate aminotransferase (AGT) activity.
C. Member has relatively preserved kidney function (e.g., eGFR of greater than or equal to 30 mL/min/1.73 m2).
D. The requested medication will not be used in combination with lumasiran.
IV. CONTINUATION OF THERAPY
Authorization of 12 months may be granted for members who meet all initial authorization criteria and demonstrate a positive response to therapy (e.g., decrease or normalization in urinary and/or plasma oxalate levels, improvement in kidney function).
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. Rivfloza [package insert]. Lexington, MA: Dicerna Pharmaceuticals, Inc.; October 2023.
2. Niaudet, P. Primary hyperoxaluria. In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA, 2022.
3. Milliner DS. The primary hyperoxalurias: an algorithm for diagnosis. Am J Nephrol 2005; 25:154.
ORIGINAL EFFECTIVE DATE: 4/30/2024
MOST RECENT REVIEW DATE: 4/30/2024
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.