CurrentEmblemHealthPolicy MG.MM.PH.307

Medical Policy: Crysvita (burosumab-twza) subcutaneous injection

Defines medical necessity criteria, dosing limits, length of authorization, coding, exclusions, and renewal for Crysvita (burosumab-twza) for X-linked hypophosphatemia (XLH) and tumor-induced osteomalacia (TIO) under EmblemHealth/ConnectiCare.

Policy Summary

PayerEmblemHealth

PolicyMedical Policy: Crysvita (burosumab-twza) subcutaneous injection

Policy CodePolicy MG.MM.PH.307

Change TypeRevised (3/26/2025)

Effective Date

Next Review Date

Key ActionTreating physician must submit documentation demonstrating criteria are met (baselines: serum phosphorus, TmP/GFR, signs/symptoms, tumor resectability/genetic test results) for preauthorization or post-payment review.

SourceLink

POLICY UPDATE CHANGES

Annual Review 3/26/2025: Updated term 'mutation' to 'pathogenic variant'; clarified Epidermal Nevus Syndrome to include Cutaneous Skeletal Hypophosphatemia Syndrome; updated billable units and quantity limits.

Annual Review 5/6/2024: Added ICD-10 code E83.39 and removed eviCore management statement.

9/6/2023: Updated NDCs—removed prior NDCs and added new 42747-series NDCs.

4/4/2023: Transfer from CCUM Template to Medical CoBranded Template; retired prior policy MG.MM.PH.116.

2Covered Indications

90XLH billable units (per 14d)

180TIO billable units (per 14d)