Medical_Policy

Highmark Commercial Medical Policy - Pennsylvania

Medical Policy:	I-122-006
Topic:	Treatment of Hereditary Angioedema (HAE)
Section:	Injections
Effective Date:	May 28, 2018
Issue Date:	May 28, 2018
Last Reviewed:	February 2018

Hereditary angioedema (HAE) is a disorder characterized by recurrent episodes of non-allergic, severe swelling (angioedema) in the absence of urticaria or hives. Patients experience swelling episodes that resolve within 2 to 5 days without treatment; however laryngeal swelling can be fatal. The most common areas of the body to develop swelling are the limbs, face, intestinal tract, and airway. Minor trauma or stress may trigger an attack, but swelling often occurs without a known trigger. Episodes involving the intestinal tract cause severe abdominal pain, nausea, and vomiting. Swelling in the airway can restrict breathing and lead to life-threatening obstruction of the airway.

Bradykinin is a vasodilator that results in the swelling that is associated with angioedema. Since the angioedema is non-allergic, histamines are not involved and antihistamines are not effective. HAE can also occur because of a deficiency or malfunction of the C1 inhibitor in the body which regulates the coagulation pathway. Missing or low levels of the protein C1 esterase inhibitor (C1-INH). Lack of adequate amounts of C1-INH impact vascular permeability, causing fluid leakage in blood vessels and capillaries.

There are three types of hereditary angioedema: type I (low C1-INH levels), accounting for roughly 85% of cases; type II (poorly functioning C1-INH levels), accounting for roughly 15% of cases; and type III (normal functioning C1-INH), considered to be very rare, occurring predominantly in women. The different types have similar signs and symptoms, but are distinguished based on the underlying causes and levels of C1-INH protein. Treatment options consist of on-demand therapy for acute HAE attacks in order to reduce the severity and duration of attacks and ongoing preventive or prophylactic therapy to prevent attacks in individuals who experience frequent or severe attacks, with dramatic lifestyle impairment. Treatment options consist of various mechanisms of action, including C1 esterase inhibitors, plasma kallikrein inhibitors and bradykinin B2 receptor antagonists.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Policy Position Coverage is subject to the specific terms of the member’s benefit plan.

Prophylaxis Therapy

Hereditary Angioedema Type I and II

C1 Esterase Inhibitor [Human] (Cinryze) may be considered medically necessary when ALL of the following criteria are met:

Administration is for routine prophylaxis against hereditary angioedema (HAE) attacks in adolescents greater than or equal to nine (9) years of age and adult patients diagnosed with HAE; and
The individual must have a diagnosis of HAE where diagnosis is based on evidence of a low C4 level (C4 less than 14 mg/dL; normal range 14 to 40 mg/dL, or C4 below the lower limit of normal as defined by the laboratory performing the test) and ONE of the following laboratory tests:*
- A low C1 inhibitor (C1INH) antigenic level (C1INH less than 19 mg/dL; normal range 19 to 37 mg/dL, or C1INH antigenic level below the lower limit of normal as defined by the laboratory performing the test); or
- A normal C1INH antigenic level (C1INH normal range to 19 to 37 mg/dL) and a low C1INH functional level (functional C1INH less than 50 %); or below the lower limit of normal as defined by the laboratory performing the test); and
History of severe attack(s) with swelling of hands, feet, limbs, face, intestinal tract or airway; and
Medication is prescribed by either an immunologist, allergist or rheumatologist; and
Medications known to cause angioedema (i.e. ACE inhibitors, estrogens, angiotensin II receptor blockers) have been evaluated and discontinued when appropriate.

*Values defined by the laboratory performing the test.

The use of C1 Esterase Inhibitor [Human] (Cinryze) for all other indications is considered not medically necessary.

Procedure Codes

J0598

Hereditary Angioedema Type III

C1 Esterase Inhibitor [Human] (Cinryze) may be considered medically necessary when ALL of the following criteria are met:

Administration is for routine prophylaxis against HAE attacks in adolescents (greater than or equal to nine (9) years of age) and adult patients diagnosed with HAE; and
Documented normal or near normal C4, C1INH antigen, and C1INH function; and ONE of the following:
- Demonstration of a F12 mutation that is associated with the disease; or
- A positive family history of angioedema; and
History of severe attack(s) in the absence of concomitant hives with swelling of hands, feet, limbs, face, intestinal tract or airway; and
Medication is prescribed by either an immunologist, allergist or rheumatologist; and
Medications known to cause angioedema (i.e. ACE inhibitors, estrogens, angiotensin II receptor blockers) have been evaluated and discontinued when appropriate; and
Trial and failure of second generation antihistamines (e.g. cetirizine, desloratadine, fexofenadine, levocetirizine, or loratadine).

*Values defined by the laboratory performing the test. The use of C1 Esterase Inhibitor [Human] (Cinryze) for all other indications is considered not medically necessary.

The use of C1 Esterase Inhibitor [Human] (Cinryze) for all other indications is considered not medically necessary.

Procedure Codes

J0598

Acute Attacks

Hereditary Angioedema Type I and II

Icatibant (Firazyr), ecallantide (Kalbitor), C-1 Esterase Inhibitor [Human] (Berinert) or C1 esterase inhibitor [recombinant] (Ruconest®) may be considered medically necessary for the treatment of acute angioedema attacks when the following criteria are met:

The individual meets the following age requirement:
- Icatibant (Firazyr): greater than or equal to 18 years of age; or
- Ecallantide (Kalbitor): greater than or equal to 12 years of age; or
- C-1 esterase inhibitor [human] (Berinert): greater than or equal to five (5) years of age; or
- C1 esterase inhibitor [recombinant] (Ruconest®): greater than 13 years of age; and
The individual must have a diagnosis of HAE where diagnosis is based on evidence of a low C4 level (C4 less than 14 mg/dL; normal range 14 to 40 mg/dL, or C4 below the lower limit of normal as defined by the laboratory performing the test); and
- A low C1 inhibitor (C1INH) antigenic level (C1INH less than 19 mg/dL; normal range 19 to 37 mg/dL, or C1INH antigenic level below the lower limit of normal as defined by the laboratory performing the test); or
- A normal C1INH antigenic level (C1INH normal range to 19 to 37 mg/dL) and a low C1INH functional level (functional C1INH less than 50 %); or
- Below the lower limit of normal as defined by the laboratory performing the test); and
The individual must be experiencing at least one (1) symptom of the moderate or severe attack (e.g., airway swelling, severe abdominal pain, facial swelling, nausea and vomiting, painful facial distortion); and
Medication is prescribed by either an immunologist, allergist or rheumatologist; and
Medications known to cause angioedema (i.e. ACE inhibitors, estrogens, angiotensin II receptor blockers) have been evaluated and discontinued when appropriate; and
Patient not self-administering two acute medications on the same day ; and
Not used in combination with other approved treatments for acute HAE attacks (e.g. Berinert, Firazyr, Kalbitor or Ruconest).

The use of Icatibant (Firazyr), ecallantide (Kalbitor), C-1 Esterase Inhibitor [Human] (Berinert) or C1 esterase inhibitor [recombinant] (Ruconest®) for all other indications is considered not medically necessary.

Procedure Codes

J0596, J0597, J0598, J1290, J1744

Hereditary Angioedema Type III

Icatibant (Firazyr), Ecallantide (Kalbitor), C-1 Esterase Inhibitor [Human] (Berinert), or C1 esterase inhibitor [recombinant] (Ruconest®) may be considered medically necessary in an individual who experiences attacks associated with HAE when the following criteria are met:

The individual meets the following age requirements:
- Icatibant (Firazyr): greater than or equal to 18 years of age; or
- Ecallantide (Kalbitor): or greater than or equal to12 years of age; or
- C-1 esterase inhibitor [human] (Berinert): greater than or equal to five (5) years of age; or
- C1 esterase inhibitor [recombinant] (Ruconest®): greater than 13 years of age; and
Documented normal or near normal C4, C1INH antigen, and C1INH function; and ONE of the following:
- Demonstration of a F12 mutation that is associated with the disease; or
- A positive family history of angioedema; and
History of severe attack(s) in the absences of concomitant hives with swelling of hands, feet, limbs, face, intestinal tract or airway; and
Medication is prescribed by either an immunologist, allergist or rheumatologist; and
Medications known to cause angioedema (i.e. ACE inhibitors, estrogens, angiotensin II receptor blockers) have been evaluated and discontinued when appropriate; and
Trial and failure of second generation antihistamines (e.g. cetirizine, desloratadine, fexofenadine, levocetirizine, or loratadine); and
Not used in combination with other approved treatments for acute HAE attacks (e.g. Berinert, Firazyr, Kalbitor or Ruconest).

According to an International Consensus Statement on Hereditary Angioedema testing must be performed more than once to confirm the diagnosis.

Procedure Codes

J0596, J0597, J0598, J1290, J1744

Dosage recommendations per the FDA label.

Refer to Pharmacy Policy Bulletins J-423 on Firazyr; and J-424 for Berinert and Ruconest.

Place of Service: Outpatient

Treatment of Hereditary Angioedema (HAE) is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

The policy position applies to all commercial lines of business

Denial Statements

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

Links

Link to Provider Resource Center for the Medical Policy Update

06/2017, Revised Criteria for Treatment of Hereditary Angioedema (HAE)
03/2018, Coverage Criteria Revised for C-1 Esterase Inhibitor [Human] (Berinert)

Link to Diagnosis Codes

Link to References

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

Provides free aids and services to people with disabilities to communicate effectively with us, such as:

Qualified sign language interpreters

Written information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as:

Qualified interpreters

Information written in other languages

If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.