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ph-0079

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Lumizyme® (alglucosidase alfa)

Policy Number: PH-0079

Intravenous

 

Last Review Date: 02/02/2023

Date of Origin:  11/28/2011

Dates Reviewed: 12/2011, 02/2013, 02/2014, 08/2014, 07/2015, 10/2016, 10/2017, 10/2018, 02/2019, 02/2020, 02/2021, 09/2021, 02/2022, 02/2023

FOR PEEHIP Members Only -Coverage excludes the provider-administered medication(s) outlined in this drug policy from being accessed through a specialty pharmacy. It must be obtained through buy and bill.

  1. Length of Authorization

Coverage will be provided for 12 months and may be renewed.

  1. Dosing Limits

A. Quantity Limit (max daily dose) [NDC Unit]:

  • Lumizyme 50 mg single-dose vial: 46 vials every 14 days

B. Max Units (per dose and over time) [HCPCS Unit]:

  • 230 billable units every 14 days
  1. Initial Approval Criteria 1,4

Depending on member benefits, additional criteria may apply for coverage of this drug in an outpatient facility setting. Verify any Site of Service requirements with the member’s plan and refer to the Voluntary Site of Service Policy or the Mandatory Site of Service Policy for additional information.

         Coverage is provided in the following conditions:

  • Documented baseline age-appropriate values for one or more of the following:
    • Infantile-onset disease: muscle weakness, motor function, respiratory function, cardiac involvement, percent predicted forced vital capacity (FVC), and/or 6-minute walk test (6-MWT); OR
    • Late-onset (non-infantile) disease: FVC and/or 6-MWT; AND

**NOTE: For very young patients in which FVC or 6-MWT are not suitable for measuring, requests will be reviewed on a case-by case basis.

Universal Criteria 1

Submission of medical records related to the medical necessity criteria is REQUIRED on all requests for authorizations. Records will be reviewed at the time of submission. Please provide documentation via direct upload through the PA web portal or by fax.

  • Will not be used in combination with other enzyme replacement therapies (i.e., avalglucosidase-alfa, etc.); AND
  • Patients susceptible to fluid volume overload or those with an acute underlying respiratory illness or compromised cardiac or respiratory function, will be closely monitored for exacerbation of their cardiac or respiratory status during infusion; AND

Pompe Disease (Acid Alpha-Glucosidase (GAA) deficiency) † Ф 1,4

  • Diagnosis has been confirmed by one of the following:
    • Deficiency of acid alpha-glucosidase (GAA) enzyme activity; OR
    • Detection of biallelic pathogenic variants in the GAA gene by molecular genetic testing

FDA approved indication(s); Compendia recommended indication(s); Ф Orphan Drug

  1. Renewal Criteria 1,4

Coverage may be renewed based on the following criteria:

  • Patient continues to meet the universal and other indication-specific relevant criteria such as concomitant therapy requirements (not including prerequisite therapy), performance status, etc. identified in section III; AND
  • Absence of unacceptable toxicity from the drug. Examples of unacceptable toxicity include: anaphylaxis and hypersensitivity reactions, immune-mediated cutaneous reactions, systemic immune-mediated reactions, acute cardiorespiratory failure, cardiac arrhythmia during general anesthesia, etc.; AND
  • Patient is being monitored for antibody formation (including neutralizing antibodies); AND
  • Patient has demonstrated a beneficial response to therapy compared to pretreatment age-appropriate baseline values in one or more of the following:
    • Infantile-onset disease: stabilization or improvement in muscle weakness, motor function, respiratory function, cardiac involvement, FVC and/or 6-MWT; OR
    • Late-onset (non-infantile) disease: stabilization or improvement in FVC and/or 6-MWT
  1. Dosage/Administration

    Indication

    Dose

    Pompe Disease

    Administer 20 mg/kg body weight as an intravenous (IV) infusion every 2 weeks

  2. Billing Code/Availability Information

HCPCS Code:

  • J0221 – Injection, alglucosidase alfa, (Lumizyme), 10 mg; 1 billable unit = 10 mg

NDC:

  • Lumizyme 50 mg single-dose vial for injection: 58468-0160-xx
  1. References
  1. Lumizyme [package insert]. Cambridge, MA; Genzyme Corporation; May 2022. Accessed January 2023.
  2. Cupler EJ, Berger KI, Leshner RT, et al. Consensus treatment recommendations for late-onset Pompe disease. Muscle Nerve. 2012 Mar; 45(3):319-33. doi: 10.1002/mus.22329. Epub 2011 Dec 15.
  3. Kishnani PS, Steiner RD, Bali D, et al. Pompe disease diagnosis and management guidelines. Genet Med 2006; 8:267-88.
  4. Nancy L, Bailey L. Pompe Disease. GeneReviews. www.ncbi.nlm.nih.gov/books/NBK1261/. Initial Posting: August 31, 2007; Last Update: May 11, 2017. Accessed on January 09, 2023.
  5. Tarnopolsky M, Katzberg H, Petrof BJ, et al. Pompe Disease: Diagnosis and Management. Evidence-Based Guidelines from a Canadian Expert Panel. Can J Neurol Sci. 2016 Jul;43(4):472-85.
  6. Kishnani PS, Hwu WL, et al. Introduction to the Newborn Screening, Diagnosis, and Treatment for Pompe Disease Guidance Supplement. Pediatrics 2017 Jul:(1):S1-S3.
  7. van der Ploeg AT, Clemens PR, Corzo D, et al. A randomized study of alglucosidase alfa in late-onset Pompe's disease. N Engl J Med. 2010 Apr 15;362(15):1396-406. doi: 10.1056/NEJMoa0909859.
  8. Nicolino M, Byrne B, Wraith JE, et al. Clinical outcomes after long-term treatment with alglucosidase alfa in infants and children with advanced Pompe disease. Genet Med. 2009 Mar;11(3):210-9. doi: 10.1097/GIM.0b013e31819d0996.
  9. Sawada T, Kido J, Nakamura K. Newborn Screening for Pompe Disease. Int J Neonatal Screen. 2020 Jun; 6(2): 31.Published online 2020 Apr 5. doi: 10.3390/ijns6020031

Appendix 1 – Covered Diagnosis Codes

ICD-10

ICD-10 Description

E74.02

Pompe disease

Appendix 2 – Centers for Medicare and Medicaid Services (CMS)

Medicare coverage for outpatient (Part B) drugs is outlined in the Medicare Benefit Policy Manual (Pub. 100-2), Chapter 15, §50 Drugs and Biologicals. In addition, National Coverage Determination (NCD), Local Coverage Determinations (LCDs), and Local Coverage Articles (LCAs) may exist and compliance with these policies is required where applicable. They can be found at: https://www.cms.gov/medicare-coverage-database/search.aspx. Additional indications may be covered at the discretion of the health plan.

Medicare Part B Covered Diagnosis Codes (applicable to existing NCD/LCD/LCA): N/A

Medicare Part B Administrative Contractor (MAC) Jurisdictions

Jurisdiction

Applicable State/US Territory

Contractor

E (1)

CA, HI, NV, AS, GU, CNMI

Noridian Healthcare Solutions, LLC

F (2 & 3)

AK, WA, OR, ID, ND, SD, MT, WY, UT, AZ

Noridian Healthcare Solutions, LLC

5

KS, NE, IA, MO

Wisconsin Physicians Service Insurance Corp (WPS)

6

MN, WI, IL

National Government Services, Inc. (NGS)

H (4 & 7)

LA, AR, MS, TX, OK, CO, NM

Novitas Solutions, Inc.

8

MI, IN

Wisconsin Physicians Service Insurance Corp (WPS)

N (9)

FL, PR, VI

First Coast Service Options, Inc.

J (10)

TN, GA, AL

Palmetto GBA, LLC

M (11)

NC, SC, WV, VA (excluding below)

Palmetto GBA, LLC

L (12)

DE, MD, PA, NJ, DC (includes Arlington & Fairfax counties and the city of Alexandria in VA)

Novitas Solutions, Inc.

K (13 & 14)

NY, CT, MA, RI, VT, ME, NH

National Government Services, Inc. (NGS)

15

KY, OH

CGS Administrators, LLC

 

 

 

LUMIZYME® (alglucosidase alfa) Prior Auth Criteria
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