Fish Oil Triglycerides (Omegaven)
Defines medical necessity criteria, authorization durations, coding, FDA indication, dosing and limitations for Omegaven (fish oil triglycerides) for Cigna-administered health benefit plans, focused on pediatric treatment of parenteral nutrition-associated cholestasis (PNAC).
No material changes to clinical coverage or criteria in this policy.
Coverage Summary
Coverage stance: covered_with_criteria for Omegaven when used to treat pediatric parenteral nutrition-associated cholestasis (PNAC). Scope summary: Defines medical necessity criteria, authorization durations, coding, FDA indication, dosing and limitations for Omegaven (fish oil triglycerides) for Cigna-administered health benefit plans, focused on pediatric treatment of parenteral nutrition-associated cholestasis (PNAC). Receipt of sample product does not satisfy coverage criteria.