Criteria
Coverage is subject to the specific terms of the member’s benefit plan.
The use of capsaicin patch (Qutenza) may be considered medically necessary when ALL of the following criteria are met:
- The individual must meet FDA-approved label for use (e.g., use outside of studied population will be considered investigational); and
- The prescriber is a, or in consult with, a pain specialist; and
- The individual must have failed a three (3)-month treatment of topical lidocaine patch.
Initial Authorization: Six (6) months
Reauthorization Criteria
Continuation of therapy with capsaicin patch (Qutenza) may be considered medically necessary when the following are met:
- The individual must have experienced and maintained clinical benefit since starting treatment with the requested medication, as evidenced by medical documentation (e.g., chart notes) attached to the request (subject to clinical review).
Continuation Authorization: 12 months
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
