Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Pozelimab-bbfg (Veopoz) may be considered medically necessary when
ALL
the following criteria are met
:
-
Individual is one (1) year of age or older;
and
-
Confirmed diagnosis of CD55-deficient protein-losing enteropathy (CHAPLE disease) consisting of
ALL
the following:
-
Hypoalbuminemia (serum albumin concentration of less than 3.2 g/dL);
and
-
History of
one or more
of the following symptoms:
-
Diarrhea;
or
-
Facial edema;
or
-
Peripheral edema;
or
-
Abdominal pain;
and
-
Genetic test confirming biallelic CD55 loss-of-function mutation.;
and
-
Individual is not receiving concomitant therapy with intravenous immunoglobulins (IVIG).
Reauthorization Criteria
Continuation of therapy with pozelimab-bbfg (Veopoz) may be considered medically necessary when the following criteria are met:
- Provider attestation that individual has demonstrated positive clinical response to therapy (i.e. normalization of serum albumin concentrations and improvement of symptoms).
The use of pozelimab-bbfg (Veopoz) 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
