Criteria
Coverage is subject to the specific terms of the member’s benefit plan.
Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the www.fepblue.org website.
The use of capsaicin patch (Qutenza) may be considered medically necessary when ALL of the following criteria are met:
- The individual is 18 years of age or older; and
- ONE of the following:
- The individual has postherpetic neuralgia that has persisted for at least six (6) months following healing of herpes zoster rash; or
- The individual has neuropathic pain associated with diabetic peripheral neuropathy of the feet and does not have uncontrolled diabetes (defined by A1C ≥11%); and
- A documented baseline Numerical Pain Rating Scale (NPRS) is submitted for the individual; and
- The individual had an inadequate response or has a contraindication to ALL of the following:
- Tricyclic antidepressant (e.g., amitriptyline, nortriptyline, desipramine); and
- Gabapentin; and
- Pregabalin; and
- Lidocaine 5% patch; and
- Another capsaicin product; and
- The prescriber is a specialist in the area of the individual’s diagnosis or the prescriber has consulted with a specialist in the area of the individual’s diagnosis.
Reauthorization Criteria
Continuation of therapy with capsaicin patch (Qutenza) may be considered medically necessary when the following are met:
- The individual has previously been approved for capsaicin patch (Qutenza) through Blue Cross Blue Shield of North Dakota's precertification process; and
- The individual has had clinical benefit from capsaicin patch (Qutenza) as evidenced by a documented decrease in NPRS score.
Capsaicin patch (Qutenza) for any other indication not listed within this policy will be considered experimental/investigational and, therefore, not-covered. Scientific evidence does not support its efficacy or safety for any other indications.
Procedure Codes
