BlueCross BlueShield of Tennessee Medical Policy Manual

Corticotropin Therapy

Does not apply to Medicare Advantage.

NDC CODE(S)

63004-8710-XX - Acthar H.P Gel 80 units/ml injection (Mallinckrodt Pharmaceuticals)

DESCRIPTION

Corticotropin is a highly purified sterile preparation of adrenocorticotropic hormone (ACTH).  It is currently only commercially available in gelatin to provide a prolonged release in tissues after subcutaneous or intramuscular injection.  ACTH stimulates the adrenal cortex to produce multiple hormones, including cortisol, corticosterone and aldosterone.

POLICY

MEDICAL APPROPRIATENESS

INITIAL APPROVAL

RENEWAL CRITERIA

INDICATION(S)

DOSAGE & ADMINISTRATION

Infantile spasms

75 units/m² intramuscularly given twice daily for 2 weeks, then taper the dose over a 2 week period (e.g., 30 units/m2 in the morning for 3 days; 15 units/m2 in the morning for 3 days; 10 units/m2 in the morning for 3 days; and 10 units/m2 every other morning for 6 days)

LENGTH OF AUTHORIZATION

Coverage will be provided for 1 month and may be renewed

Refer to DOSAGE LIMITS below

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.

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, the express terms of the health plan will govern.

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).

SOURCES

BlueCross BlueShield Association. Medical Policy Reference Manual. (10:2017). Repository corticotropin injection (5.01.17). Retrieved January 4, 2019 from BlueWeb.

MICROMEDEX Healthcare Series. Drugdex Drug Evaluations. (2018, November). Corticotropin. Retrieved January 4, 2019 from MICROMEDEX Healthcare Series.

U. S. Food and Drug Administration. (2018, April). Center for Drug Evaluation and Research. H. P. Acthar gel (repository corticotropin) injection, gel for intramuscular / subcutaneous use. Retrieved January 4, 2019 from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/008372s057lbl.pdf.

ORIGINAL EFFECTIVE DATE: 9/14/2008

MOST RECENT REVIEW DATE:  7/9/2019

ID_MRx

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.

 

 

DOSAGE LIMITS

Maximum billable units per dose and over time by indication as a Medical Benefit; up to 40 units = 1 billable unit

DIAGNOSIS

MAXIMUM UNITS

Infantile spasms

35 billable units every 28 days