Medical Policy Updates

Medical Policy Update for November 4, 2021

Medical Policy Revision
Anifrolumab-fnia (Saphnelo™) Original medical policy criteria issued.
Botulinum Toxin Injection Added hemifacial spasm as a covered indication; updated criteria for blepharospasm to include blepharospasm associated with dystonia or facial nerve (VII) disorders (including benign essential blepharospasm and hemifacial spasm) separately without step therapy requirement.
Enzyme Replacement Therapy (ERT) for Lysosomal Storage Disorders Added newly approved Nexviazyme to policy for treatment of late-onset Pompe disease in patients 1 year or older, added drug to SOC criteria and associated dosing and maximum units to FDA label reference table; updated Pompe disease criteria to include genetic testing as option for diagnosis confirmation.
Lumasiran (Oxlumo™) Removed baseline diagnostic metabolic testing requirements, and no secondary causes of hyperoxaluria; added use to lower urinary oxalate levels and no FDA labeled contraindications to therapy for clarity according to FDA labeling; reformatted continuation criteria to require a positive clinical response while using the medication as demonstrated by improvement, stabilization, or slowed worsening of disease.