Belimumab (Benlysta) (Medicaid Expansion)

Policy ID: ME-I-33-017-01

Section: Injections

Effective Date: December 09, 2024

Last Reviewed: November 19, 2024

Applies To: Medicaid Expansion Only

Description

Belimumab (Benlysta®) is a human monoclonal antibody that specifically recognizes and blocks the biological activity of B-lymphocyte stimulator. Elevated levels of BLyS prolong the survival of B lymphocytes (B cells) which can contribute to the production of autoantibodies - antibodies that target the body's own tissues. Studies have shown that belimumab can reduce autoantibody levels and help control autoimmune disease activity. Belimumab (Benlysta) is available in a lyophilized powder that is administered intravenously by a health care professional and is also available as a subcutaneous injection that may be self-administered by individuals 18 years of age and older.

Policy Application

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

Belimumab (Benlysta) for intravenous use may be considered medically necessary when ALL of the following criteria are met:

Systemic Lupus Erythematosus

Individual is five (5) years of age or older; and
Individual has a diagnosis of active systemic lupus erythematosus; and
Individual will continue to receive concomitant standard of care for treatment of systemic lupus which includes ANY of the following (alone or in combination):
- Corticosteroids (e.g. prednisone); or
- Antimalarials (i.e. hydroxychloroquine); or
- Immunosuppressives (e.g. azathioprine, mycophenolate mofetil, or methotrexate); and
Initial authorization will be up to 12 months.

Lupus Nephritis

Individual is five (5) years of age or older, and
Individual has a diagnosis of active lupus nephritis; and
Individual is receiving standard therapy (e.g. corticosteroids, immunosuppressive drugs, medications to control blood pressure or prevent blood clots if indicated) ; and
Initial authorization will be up to 12 months.

Reauthorization Criteria

Continuation of therapy with belimumab (Benlysta) may be considered medically necessary when the following criteria are met:

The individual has one of the above diagnoses; and
Provider attestation that individual has demonstrated disease stability or a beneficial response to therapy; and
Reauthorization valid for 12 months.

Procedure Code

J0490

NOTE: In addition to the above criteria, product specific dosage and/or frequency limits may apply in accordance with the United States Food and Drug Administration (U.S. FDA)-approved product prescribing information, national compendia, Centers for Medicare and Medicaid Services (CMS) and other peer reviewed resources or evidence-based guidelines.

Diagnosis Codes

M32.0

M32.10

M32.11

M32.12

M32.13

M32.14

M32.15

M32.19

M32.8

M32.9

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 11-19-2024 Effective December 09, 2024

Adopted Medicaid Expansion specific policy

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

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