Benznidazole prior authorization for Chagas disease
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This policy governs prior authorization requirements for benznidazole when used to treat Chagas disease for CareOregon members; it specifies diagnostic confirmation and prescriber specialty requirements and approval length.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial therapy
Covered when ALL of the following are met
Diagnostic confirmation AND specialist prescribing
- Diagnostic evidence of T. cruzi infection (any one required): One of the following diagnostic confirmations is required: (1) T. cruzi trypomastigotes detected on microscopy, (2) detection of T. cruzi DNA by PCR assay, OR (3) two positive diagnostic serologic tests using two different techniques and antigens showing IgG antibodies to T. cruzi.
- Prescriber requirement: Prescription must be written by or currently supervised by a cardiologist or infectious disease specialist.
No other indications or exclusions are specified beyond the diagnostic and prescriber requirements in this policy. Coverage is limited to treatment of Chagas disease when the specified laboratory confirmation of T. cruzi infection and the prescriber specialty/supervision requirement are met.
Provider Actions & Authorization Rules
Prior authorization required; approval = 60 days
Benznidazole requires prior authorization. Approval is granted for 60 days to cover one course of treatment.
No step therapy required
No step therapy requirements are specified for benznidazole in this guideline.
Required diagnostic documentation for T. cruzi
Provide documentation confirming infection with Trypanosoma cruzi using one of the listed diagnostic methods.
- Detection of T. cruzi trypomastigotes on microscopy
- Detection of T. cruzi DNA by PCR assay
- Two positive diagnostic serologic tests using two different techniques and antigens showing IgG antibodies to T. cruzi
Denial triggers: missing confirmation or specialist oversight
A request may be denied if required diagnostic confirmation is not provided or if the prescription is not written by or currently supervised by an appropriate specialist.
- Missing one of the specified diagnostic confirmations for T. cruzi
- Prescription not written by or not currently supervised by a cardiologist or infectious disease specialist
Definitions
Background
Benznidazole is indicated for treatment of Chagas disease caused by Trypanosoma cruzi. This policy requires laboratory confirmation of infection by one of the following: detection of T. cruzi trypomastigotes on microscopy; detection of T. cruzi DNA by PCR; or two positive diagnostic serologic tests using two different techniques and antigens showing IgG antibodies to T. cruzi. In addition, the prescription must be written by or currently supervised by a cardiologist or infectious disease specialist to qualify for coverage.
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