Camzyos (mavacamten) prior authorization
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Prior authorization requirements for initiating and renewing Camzyos (mavacamten) for members with obstructive hypertrophic cardiomyopathy; applies to providers submitting requests to CareOregon.
No material clinical or coverage changes in this revision.
Coverage Criteria for Camzyos (mavacamten)
Initial Therapy Criteria
Covered when ALL of the following are met
All elements must be documented.
All criteria listed must be documented for initial approval; initial approvals are granted for 6 months per prior authorization policy.
Continuation/Reauthorization Criteria
Covered when ALL of the following are met
Reauthorization approvals are for 12 months and require documentation of recent LVEF and clinical improvement.
Members with other disorders that can cause cardiac hypertrophy are excluded from coverage under these criteria. Specifically, Fabry disease, cardiac amyloidosis, and Noonan syndrome must be absent for the member to meet the approval requirements for Camzyos (mavacamten).
Clinical Thresholds and Key Values
Provider Requirements and Prior Authorization
Prior authorization required — initial 6 months; reauthorization 12 months
Prior authorization is required for Camzyos. Initial approvals are issued for 6 months; reauthorization approvals are issued for 12 months and require documentation of recent LVEF and clinical improvement.
Medication trial requirement — guideline beta-blocker or CCB
Member must be currently taking a guideline-recommended beta-blocker or a calcium channel blocker for symptom management, or have a documented medical reason not to take these agents.
- Examples of beta-blockers listed: atenolol, metoprolol, propranolol
- Examples of calcium channel blockers listed: diltiazem, verapamil
Required clinical documentation — ECHO, LVEF, LVOT gradient, wall thickness, NYHA class
Submit medical records/chart notes confirming NYHA class II or III symptoms, a baseline echocardiogram with left ventricular ejection fraction (LVEF) and left ventricular outflow tract (LVOT) gradient and left ventricular wall thickness, and documentation regarding candidacy for septal reduction procedures.
- Baseline LVEF ≥ 55% on echocardiogram (initial)
- LVOT gradient ≥ 50 mm Hg
- Left ventricular wall thickness ≥ 15 mm (or ≥ 13 mm if family history of HCM)
- Documentation that member is not a candidate for alcohol septal ablation or septal myectomy
- For reauthorization: most recent ECHO within 12 weeks showing LVEF ≥ 50% and provider attestation of symptom/NYHA/class or functional improvement
Denial risk — missing required diagnostic criteria or documentation
Requests lacking the required diagnostic measurements or supporting notes may be denied — specifically missing baseline LVEF, LVOT gradient, wall thickness, NYHA class documentation, or absence of documentation about prior medication use or noncandidacy for septal procedures.
- Denial risk if baseline LVEF (≥55% initial) or most recent LVEF (≥50% for reauthorization) is not documented
- Denial risk if LVOT gradient (≥50 mm Hg) or wall thickness thresholds are not recorded
- Denial risk if chart notes do not confirm NYHA class II/III or do not document trial of guideline medications or medical reasons for not using them
- Denial risk if documentation that the member is not a candidate for alcohol septal ablation or septal myectomy is missing
Background
Obstructive hypertrophic cardiomyopathy (oHCM) is defined here by asymmetric left ventricular hypertrophy with dynamic obstruction of the left ventricular outflow tract that produces symptoms such as exertional dyspnea and reduced functional capacity. For authorization purposes, the diagnosis must be documented by a baseline echocardiogram showing a left ventricular ejection fraction of >= 55%, medical records confirming NYHA class II or III symptoms, and hemodynamic and anatomic evidence of obstruction (a LVOT gradient >= 50 mm Hg and left ventricular wall thickness meeting the policy threshold). Management considerations referenced in the criteria include guideline-directed medical therapy (beta-blockers or nondihydropyridine calcium channel blockers), evaluation for septal reduction procedures (alcohol septal ablation or septal myectomy), and use of targeted agents such as mavacamten when the specified clinical and diagnostic thresholds are met.
Definitions
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