CurrentCignaPolicy N/A

prior_authorization_policy_gaucher_disease_miglustat

Defines prior authorization requirements and medical necessity criteria for miglustat capsules (Zavesca, generic) for treatment of Gaucher disease type 1 (FDA-approved) and Niemann-Pick disease type C (off-label with supportive evidence). Also lists a not-covered condition (concomitant use with other approved Gaucher therapies).

Policy Summary

PayerCigna

Policyprior_authorization_policy_gaucher_disease_miglustat

Policy CodePolicy N/A

Change TypeAdded NPC indication; added concomitant-use exclusion; wording revisions

Effective Date

Next Review Date

Key ActionPrior authorization is recommended for miglustat; approvals provided for 1 year for listed indications.

POLICY UPDATE CHANGES

Niemann-Pick disease Type C was added as a new condition of approval.

Wording for genetic confirmation for Gaucher Disease Type 1 was changed to 'showing biallelic pathogenic glucocerebrosidase (GBA) gene variants'.

Condition Not Covered: Concomitant use with other approved therapies for Gaucher disease was added.

Annual reviews noted with statements of 'No criteria changes' on certain dates.

2Covered Indications

1Not Covered

1Approval Duration (yrs)

Coverage Summary

Scope: Defines prior authorization requirements and medical necessity criteria for miglustat capsules (Zavesca, generic) for treatment of Gaucher disease type 1 (FDA-approved) and Niemann-Pick disease type C (off-label with supportive evidence).

Coverage stance: Covered with criteria — approvals provided when authorization criteria are met.

Subject and status: Miglustat (Zavesca) prior authorization for Gaucher disease and Niemann-Pick disease type C; CURRENT.

Background: Miglustat is FDA-approved as monotherapy for mild to moderate Gaucher disease type 1 in adults when enzyme replacement therapy is not an option, and there is supportive evidence for use in Niemann-Pick disease type C (NPC) though it is not FDA-approved for NPC.

Approval duration and threshold: Approvals are provided for 1 year for the listed indications; minimum age threshold for NPC is ≥ 2 years.

Policy Summary - Key Metadata

Covered Indications2

Not Covered Conditions1

Approval Duration1 year

Minimum age for NPC>= 2 years

Medical Necessity Criteria

FDA-Approved Indication - Gaucher Disease Type 1 (Approve for 1 year)

Approve for 1 year if the patient meets BOTH of the following (A and B):

ALL of the following

Diagnosis established by ONE of the following
- Demonstration of deficient beta-glucocerebrosidase activity in leukocytes or fibroblasts
- Molecular genetic test showing biallelic pathogenic glucocerebrosidase (GBA) gene variants
Medication is prescribed by or in consultation with a geneticist, endocrinologist, metabolic disorder subspecialist, or a physician who specializes in the treatment of Gaucher disease or related disorders

Other Uses with Supportive Evidence - Niemann-Pick Disease Type C (Approve for 1 year)

Provider Actions & Documentation Requirements

Prior Authorization

Prior authorization required

Prior authorization is required for prescription benefit coverage of miglustat capsules. Approvals are provided for the duration noted in the policy (1 year for the listed indications).

Documentation Required

Diagnostic confirmation required - Gaucher disease

For Gaucher disease, document either deficient beta-glucocerebrosidase activity in leukocytes or fibroblasts OR a molecular genetic test showing biallelic pathogenic glucocerebrosidase (GBA) gene variants.

Coding

DrugNDCCovered

No codes listed

Background, Evidence, and Definitions

Miglustat is a glucosylceramide synthase inhibitor that functions as a substrate reduction therapy by decreasing production of glucosylceramide so residual β-glucocerebrosidase activity is more effective.

FDA indication: Miglustat capsules (Zavesca, generic) are indicated as monotherapy for the treatment of mild to moderate Gaucher disease type 1 in adults when enzyme replacement therapy is not a therapeutic option (for example, due to allergy, hypersensitivity, or poor venous access).

Supportive evidence for NPC: Although not FDA-approved for Niemann-Pick disease Type C, miglustat has been used off-label for NPC; consensus clinical management guidelines (INPDR 2018) recommend considering miglustat for patients with confirmed NPC, with diagnosis confirmed by molecular genetic analysis of NPC1 or NPC2.

Examples of other approved Gaucher therapies (not to be used concomitantly with miglustat per policy) include Cerezyme (imiglucerase), Elelyso (taliglucerase alfa), Vpriv (velaglucerase alfa), and Cerdelga (eliglustat).

Source	Date/Reference
Zavesca prescribing information
August 2022
Consensus guideline for NPC - INPDR
2018

Biallelic pathogenic variants: Pathogenic variants present in both copies of the specified gene (for example, GBA for Gaucher disease or NPC1/NPC2 for Niemann-Pick disease type C) as demonstrated by molecular genetic testing.

For Gaucher disease type 1, diagnosis can be established by either demonstration of deficient beta-glucocerebrosidase activity in leukocytes or fibroblasts or by a molecular genetic test showing biallelic pathogenic GBA gene variants.

For NPC, diagnosis is established by molecular genetic testing showing biallelic pathogenic variants in either NPC1 or NPC2.

Revision History

08/14/2024Change

Niemann-Pick disease Type C was added as a new condition of approval.

05/29/2024Change

Conditions Not Covered: Concomitant use with other approved therapies for Gaucher disease was added.

05/10/2023Change

Gaucher Disease Type 1: Confirmation of a genetic mutation in the glucocerebrosidase gene was rephrased to more specifically state 'genetic test documenting biallelic pathogenic glucocerebrosidase (GBA) gene variants'.

Policy Summary

PayerCigna

Policyprior_authorization_policy_gaucher_disease_miglustat

Policy CodePolicy N/A

Change TypeAdded NPC indication; added concomitant-use exclusion; wording revisions

Effective Date

Next Review Date

Key ActionPrior authorization is recommended for miglustat; approvals provided for 1 year for listed indications.

On This Page

Approve for 1 year if the patient meets ALL of the following (A, B, and C):

ALL of the following

Patient is ≥ 2 years of age>= 2 years
Diagnosis established by a molecular genetic test showing biallelic pathogenic variants in either the NPC1 or NPC2 gene
Medication is prescribed by or in consultation with a geneticist, endocrinologist, metabolic disorder subspecialist, or a physician who specializes in the treatment of NPC or related disorders

Conditions Not Covered (Not Medically Necessary)

Miglustat is considered not medically necessary for ANY other use(s) including the following:

Concomitant use with other treatments approved for Gaucher disease (examples listed: imiglucerase/Cerezyme, taliglucerase alfa/Elelyso, velaglucerase alfa/Vpriv, eliglustat/Cerdelga)

Documentation Required

Diagnostic confirmation required - NPC

For Niemann-Pick disease type C (NPC), document a molecular genetic test showing biallelic pathogenic variants in either the NPC1 or NPC2 gene.

Documentation Required

Specialist prescribing or consult

Medication must be prescribed by or in consultation with a geneticist, endocrinologist, metabolic disorder subspecialist, or a physician who specializes in the treatment of the relevant disease (e.g., Gaucher disease or NPC).

Geneticist
Endocrinologist
Metabolic disorder subspecialist
Physician who specializes in the treatment of the relevant disease

Denial Risk

Concomitant therapy contraindication

Claims for miglustat used concomitantly with other treatments approved for Gaucher disease may be considered not medically necessary and denied.

Examples of approved Gaucher therapies listed in the policy: imiglucerase (Cerezyme), taliglucerase alfa (Elelyso), velaglucerase alfa (Vpriv), eliglustat (Cerdelga)

10/30/2024Change

Gaucher Disease Type 1: For confirmation by genetic testing, the term 'documenting' was rephrased to 'showing'. Niemann-Pick disease Type C: This was added as a new condition of approval.

05/07/2025Last ReviewLatest

Annual review completed (No criteria changes noted on this review date).