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 has previously been approved for capsaicin patch (Qutenza) through Blue Cross Blue Shield of North Dakota's precertification process;
and
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);
and
- The prescriber is a, or in consult with, a pain specialist.
Continuation Authorization: 12 months
The use of capsaicin patch (Qutenza) for all other indications not listed in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature.
Procedure Code
