CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Ryoncil (remestemcel-L) for steroid-refractory acute graft-versus-host disease (SR-aGVHD) in pediatric patients

Policy governs prior authorization, coverage criteria, dosing limits, renewal criteria, and billing guidance for Ryoncil (remestemcel-L) for Medicaid, Commercial, and MMP members of Neighborhood Health Plan of Rhode Island; applies to pediatric patients aged 2 months to 17 years with steroid-refractory aGVHD.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyRyoncil (remestemcel-L) for steroid-refractory acute graft-versus-host disease (SR-aGVHD) in pediatric patients

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJun 1, 2025

Next Review Date

Key ActionSubmit medical records/chart notes via the PA web portal or fax with all authorization requests; records will be reviewed at submission.

POLICY UPDATE CHANGES

No material clinical or coverage changes

1Covered Diagnosis (ICD-10)

2Age range lower bound (months)

16Maximum total doses allowed

Coverage Summary

Policy governs prior authorization, coverage criteria, dosing limits, renewal criteria, and billing guidance for Ryoncil (remestemcel-L) for Medicaid, Commercial, and MMP members. Coverage stance: covered_with_criteria. The subject is Ryoncil (remestemcel-L-rknd) for steroid-refractory acute graft-versus-host disease (SR-aGVHD) in pediatric patients. The policy applies to pediatric patients aged >= 2 months and <= 17 years with steroid-refractory aGVHD and specifies requirements for prior authorization, specialist prescribing, age limits, and dosing/authorization limits.

Policy Thresholds

Age>= 2 months and <= 17 years

Steroid-refractory time definitionProgression within 3 days or no improvement within 7 consecutive days of treatment with methylprednisolone 2 mg/kg/day or equivalent

Dose per infusion2 x 10^6 MSC/kg per IV infusion

Maximum dosesUp to 16 total doses (225 million MSC twice weekly for 4 weeks described; initial course 8 infusions with renewal rules for additional doses)