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.
Spesolimab (Spevigo) may be considered medically necessary when 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 requested medication must be prescribed by, or in consult with, a specialist in the member's treated diagnosis (i.e. dermatologist);
and
-
Documentation of the baseline labs, signs or symptoms that can be utilized for comparison to show the individual has experienced clinical benefit upon renewal has been submitted with request;
and
- The individual has not received two (2) or more infusions for the current flare.
Length of approval:
One (1) month for up to two 900mg doses
The use of spesolimab (Spevigo)
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
