Covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
"The member has viremia despite 3 or more prior months of therapy with at least one appropriate regimen used to treat HIV;" — documentation of viremia and prior therapies (>= 3 months) required.
"The member has viremia and documented resistance or intolerance to at least one appropriate regimen used to treat HIV." — documentation of viremia and laboratory or clinical evidence of resistance or intolerance required.
For continuation: documentation that "the member has had a positive or stable virologic response to enfuviritide."
Use of ICD-10 code B20 (Human immunodeficiency virus [HIV] disease) when selection criteria are met.
Use of HCPCS J1324 (Injection, enfuvirtide, 1 mg) when selection criteria are met.
If applicable, pediatric age and weight documentation: age 6 years or older and weight at least 11 kg for pediatric dosing per background/FDA labeling.
Key Coverage Criteria
Aetna considers enfuvirtide (Fuzeon) injection medically necessary for the treatment of human immunodeficiency virus type 1 (HIV-1) infection when either of the following criteria is met:
The member has viremia despite 3 or more prior months of therapy with at least one appropriate regimen used to treat HIV;
The member has viremia and documented resistance or intolerance to at least one appropriate regimen used to treat HIV.
Aetna considers continuation of enfuvirtide (Fuzeon) therapy medically necessary for treatment of HIV-1 infection when the member has had a positive or stable virologic response to enfuviritide.
HCPCS code J1324 (Injection, enfuvirtide, 1 mg) covered if selection criteria are met.
ICD-10 code B20 (Human immunodeficiency virus [HIV] disease) covered if selection criteria are met.
1 Active Policy
AETNA-CPB-0671, Enfuvirtide (Fuzeon)
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