Medical Drug Clinical Criteria - Tegsedi (inotersen)
Clinical criteria for medical-benefit coverage and prior authorization of Tegsedi (inotersen) for treatment of polyneuropathy of hereditary transthyretin-mediated (hATTR) amyloidosis in adults, including initial and continuation criteria, exclusions, quantity limits, coding guidance, and safety monitoring references.
8/15/2025 - Annual Review: Add diagnosis criteria to continuation criteria; remove renal and hepatic exclusions; add Attruby to may not be used in combination criteria; administrative update to add documentation; coding reviewed: removed ICD-10-CM E85.2-E85.9, G62.9; updated HCPCS descriptions.
8/16/2024 - Annual Review: Add Wainua to may not be used in combination criteria.
8/21/2020 - Annual Review: Add continuation criteria to Tegsedi clinical criteria and add quantity limit.
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