Mirikizumab-mrkz (Omvoh) IV (Medicaid Expansion)

Policy ID: ME-I-9902-001-04

Section: Injections

Effective Date: January 01, 2024

Revised Date: October 20, 2024

Revision Effective Date: December 01, 2024

Last Reviewed: November 19, 2024

Applies To: Medicaid Expansion Only

Description

Mirikizumab-mrkz (Omvoh) is an interleukin-23 antagonist.

Mirikizumab-mrkz (Omvoh) intravenous may be covered under the medical benefit; please refer to pharmacy policies for coverage of mirikizumab-mrkz (Omvoh) self-administered subcutaneous injection.

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

Coverage is subject to the specific terms of the member's benefit plan.

Mirikizumab-mrkz (Omvoh) IV may be considered medically necessary when an individual meets the following criteria:

Ulcerative Colitis

The individual must meet recommendations found in the FDA label or compendia (e.g., diagnosis, age, dosage, frequency, route); and
The individual must have failed a three (3)-month trial of a TNF inhibitor, Entyvio, AND Skyrizi, as evidenced by paid claims or pharmacy printouts.

If approved, mirikizumab-mrkz (Omvoh) IV will be allowed as three (3) intravenous infusions over eight (8) weeks.

Mirikizumab-mrkz (Omvoh) IV 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

J2267

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

K51.00

K51.011

K51.012

K51.013

K51.014

K51.018

K51.019

K51.20

K51.211

K51.212

K51.213

K51.214

K51.218

K51.219

K51.30

K51.311

K51.312

K51.313

K51.314

K51.318

K51.319

K51.40

K51.411

K51.412

K51.413

K51.414

K51.418

K51.419

K51.50

K51.511

K51.512

K51.513

K51.514

K51.518

K51.519

K51.80

K51.811

K51.812

K51.813

K51.814

K51.818

K51.819

K51.90

K51.911

K51.912

K51.913

K51.914

K51.918

K51.919

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-2024 Effective January 01, 2024

Adopted medical policy

Internal Medical Policy Committee 3-19-2024 Effective April 01, 2024

Added new code, C9168, to the policy

Internal Medical Policy Committee 5-14-2024 Effective July 01, 2024

Added new code, J2267, to the policy
Removed code, C9168, from the policy

Internal Medical Policy Committee 11-19-2024 Effective December 01, 2024

Updated criteria based on the DHHS PDL Version 2024.6

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.

Policy ID: ME-I-9902-001-03

Section: Injections

Effective Date: January 01, 2024

Revised Date: June 12, 2024

Revision Effective Date: July 01, 2024

Last Reviewed: May 14, 2024

Archived Date: November 30, 2024

Applies To: Medicaid Expansion Only

Description

Mirikizumab-mrkz (Omvoh) is an interleukin-23 antagonist.

Mirikizumab-mrkz (Omvoh) intravenous may be covered under the medical benefit; please refer to pharmacy policies for coverage of mirikizumab-mrkz (Omvoh) self-administered subcutaneous injection.

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

Coverage is subject to the specific terms of the member's benefit plan.

Mirikizumab-mrkz (Omvoh) IV may be considered medically necessary when an individual meets the following criteria:

Ulcerative Colitis

The individual must meet recommendations found in the FDA label or compendia (e.g., diagnosis, age, dosage, frequency, route); and
The individual must have failed a three (3)-month trial of a TNF inhibitor (infliximab, adalimumab, or golimumab), vedolizumab, AND ustekinumab, as evidenced by paid claims or pharmacy printouts.

If approved, mirikizumab-mrkz (Omvoh) IV will be allowed as three (3) intravenous infusions over eight (8) weeks.

Procedure Code

J2267

Diagnosis Codes

K51.00

K51.011

K51.012

K51.013

K51.014

K51.018

K51.019

K51.20

K51.211

K51.212

K51.213

K51.214

K51.218

K51.219

K51.30

K51.311

K51.312

K51.313

K51.314

K51.318

K51.319

K51.40

K51.411

K51.412

K51.413

K51.414

K51.418

K51.419

K51.50

K51.511

K51.512

K51.513

K51.514

K51.518

K51.519

K51.80

K51.811

K51.812

K51.813

K51.814

K51.818

K51.819

K51.90

K51.911

K51.912

K51.913

K51.914

K51.918

K51.919

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-2024 Effective January 01, 2024

Adopted medical policy

Internal Medical Policy Committee 3-19-2024 Effective April 01, 2024

Added new code, C9168, to the policy

Internal Medical Policy Committee 5-14-2024 Effective July 01, 2024

Added new code, J2267, to the policy
Removed code, C9168, from the policy

Medical Policies Quick Search

Mirikizumab-mrkz (Omvoh) IV (Medicaid Expansion)

Description

Policy Application

Criteria

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer

Description

Policy Application

Criteria

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer