CurrentCignaPolicy N/A

Thrombocytopenia - Mulpleta (lusutrombopag) Coverage Criteria

Cigna coverage policy for use of Mulpleta to treat thrombocytopenia in adults with chronic liver disease scheduled for a procedure; governs prior authorization and documentation requirements for covered plans administered by Cigna Companies.

Policy Summary

PayerCigna

PolicyThrombocytopenia - Mulpleta (lusutrombopag) Coverage Criteria

Policy CodePolicy N/A

Change TypeClarified documentation requirements

Effective Date08/01/2024

Next Review DateN/A

Key ActionObtain prior authorization and include required documentation, including platelet count, to support approval.

SourceLink

POLICY UPDATE CHANGES

Added documentation requirements throughout the policy.

7 daysapproved treatment duration

<50kplatelet threshold

8-14 daystiming to procedure

≥18minimum age

Coverage Criteria for Mulpleta (lusutrombopag)

Policy Summary

PayerCigna

PolicyThrombocytopenia - Mulpleta (lusutrombopag) Coverage Criteria

Policy CodePolicy N/A

Change TypeClarified documentation requirements

Effective Date08/01/2024

Next Review DateN/A

Key ActionObtain prior authorization and include required documentation, including platelet count, to support approval.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Key Coding and Thresholds

Platelet count threshold for approval (inv-04)

Platelet count threshold< 50 x 10^9/L (< 50,000/mcL)

Context in approval criteriaRequired current platelet count for FDA‑approved indication (documentation required)

Patient populationAdults (≥ 18 years) with chronic liver disease scheduled for a procedure

Relation to clinical studiesPivotal studies included patients with platelet counts < 50 x 10^9/L

Use for authorizationUsed as a numeric threshold for prior authorization decisions per policy criteria

Provider Actions, Prior Authorization & Documentation

Prior Authorization

Prior authorization required for Mulpleta

Prior Authorization must be obtained for benefit coverage of Mulpleta; approvals are provided for the duration noted in the policy. Documentation is required as specified in the criteria when requesting authorization.

All approvals are provided for the duration noted in the policy.
Documentation is required where noted in the criteria.

Step Therapy

Not medically necessary for chronic immune thrombocytopenia and other non‑indicated uses

Mulpleta is considered not medically necessary for any use outside the FDA‑approved indication, including chronic immune thrombocytopenia; such uses should not be submitted for coverage.

Chronic immune thrombocytopenia is explicitly listed as not medically necessary.
Policy notes the list may not be all inclusive and will be updated as new data are available.

Documentation Required

Submit required documentation with authorization requests

Provide all documentation specified in the criteria when requesting coverage; acceptable documentation may include chart notes, laboratory tests, claims records, prescription receipts, and must include patient‑specific identifying information. Platelet count documentation is required where noted.

Documentation may include chart notes, laboratory tests, claims records, prescription receipts and/or other information.
All documentation must include patient‑specific identifying information.
Current platelet count < 50 x 10^9/L requires documentation per the criteria.

Billing Rule

Claims without covered codes will be denied

Do not submit claims for services without the covered diagnosis/procedure code(s) specified by the Coverage Policy; claims lacking covered code(s) under the applicable policy will be denied as not covered.

When billing, providers must use the most appropriate codes as of the effective date of submission.
Claims submitted for services that are not accompanied by covered code(s) will be denied as not covered.

Background on Mulpleta

Mulpleta (lusutrombopag) is a thrombopoietin receptor agonist indicated to treat thrombocytopenia in adults with chronic liver disease who are scheduled to undergo a procedure. For the FDA‑approved indication, treatment is 3 mg once daily for 7 days, initiated 8 to 14 days before the procedure; pivotal studies enrolled patients with platelet counts < 50 x 10^9/L (< 50,000/mcL). Prior Authorization and documentation of platelet count and timing relative to the procedure are required for coverage.

Definitions and Clinical Context

Thrombocytopenia in chronic liver disease (procedure prep) — definition (inv-10)

DefinitionPlatelet count < 50 x 10^9/L in adults with chronic liver disease scheduled for a procedure, where Mulpleta is indicated to raise platelet counts prior to the procedure.

Age requirementApplies to adults ≥ 18 years of age

Timing for procedureProcedure must be scheduled within 8 to 14 days after starting Mulpleta therapy

Treatment regimen (per overview)Recommended dose: 3 mg once daily for 7 days, initiated 8–14 days before the procedure

DocumentationCurrent platelet count < 50 x 10^9/L must be documented for approval