CurrentCommunity-CarePolicy N/A

Encelto

Defines medical benefit coverage criteria, quantity limit, authorization period, and applicable coding for revakinagene taroretcel (Encelto) when used to treat idiopathic macular telangiectasia type 2.

Policy Summary

PayerCommunity-Care

PolicyEncelto

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrior authorization is required and approval is contingent on meeting all Initial Approval Criteria (diagnosis, prescriber specialty/consultation, age ≥18, no prior receipt in the requested eye[s]).

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

1Implants authorized per eye lifetime

18+Minimum age for coverage (years)

Coverage Summary

Defines medical benefit coverage criteria, quantity limit, authorization period, and applicable coding for revakinagene taroretcel (Encelto) when used to treat idiopathic macular telangiectasia type 2. Coverage stance: covered_with_criteria. Policy subject: revakinagene taroretcel (Encelto) for idiopathic macular telangiectasia type 2.

Initial Therapy Criteria

Initial Approval Criteria

Covered when ALL of the following are met:

ALL of the following

Diagnosis of idiopathic macular telangiectasia type 2
Prescribed by a retina specialist, or by an ophthalmologist in consultation with a retina specialist
Age ≥ 18 years
Has not previously received revakinagene taroretcel (Encelto) in the requested eye(s)

Quantity Limit

If approved, coverage is subject to the following lifetime quantity limit:

ALL of the following

Authorized for quantities of up to 1 implant per affected eye per lifetime

Billing Rule

Quantity limit billing constraint

Authorize and bill no more than 1 implant per affected eye per lifetime.

J3403

Authorization Period

If approved, authorization duration:

ALL of the following

Coverage is allowed for 1 year (subject to benefit changes)

Prior Authorization

Authorization period

If approved, authorization is valid for 1 year (subject to benefit changes).

J3403

Provider Actions

Prior Authorization

Prior authorization required for initial use

Prior authorization required and approval contingent on meeting all Initial Approval Criteria.

Diagnosis of idiopathic macular telangiectasia type 2
Prescribed by a retina specialist, or by an ophthalmologist in consultation with a retina specialist
Age ≥ 18 years
Has not previously received revakinagene taroretcel (Encelto) in the requested eye(s)
J3403

Background

Medical benefit medication utilization policy for revakinagene taroretcel (Encelto) specifying clinical and administrative requirements for treatment of idiopathic macular telangiectasia type 2.

Definition — Encelto: Brand name referenced for revakinagene taroretcel.

Policy Summary

PayerCommunity-Care

PolicyEncelto

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

SourceLink

On This Page

OpenPayer

Encelto

Coverage Summary

Initial Therapy Criteria

Quantity Limit

Authorization Period

Provider Actions

Applicable Codes

Background

Clinical Evidence

Revision History