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Gene Therapy for Inherited Retinal Dystrophy
Effective date
Jan 1, 2025
Identified
Jun 20, 2026
Summary
Gene therapy with voretigene neparvovec-rzyl (Luxturna) given by subretinal injection is considered medically necessary for individuals with vision loss due to biallelic RPE65 variant-associated retinal dystrophy who meet all listed criteria. Benefits require a treatment plan submitted by the Network Provider and approved before treatment starts, along with prior authorization through Case Management from Blue Cross & Blue Shield of Mississippi. Other applications of this gene therapy are considered investigational.
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What to do
Action · 4 steps
01Already effective 01/01/2025: Under the policy exceptions, gene therapy and all gene therapy related services are excluded from coverage for Hood Packaging.
02Billing team: Confirm the treatment plan from the Network Provider was approved before treatment started and that prior authorization was obtained through Case Management from Blue Cross & Blue Shield of Mississippi.
03Confirm gene therapy services were received from a Network Provider designated and approved by the company, and that the member is not pregnant or breastfeeding.
04Confirm the record documents genetic testing confirming biallelic RPE65 pathogenic or likely pathogenic variants, and the presence of viable retinal cells, with the age limits of under 65 years or 3 years and older.
Codes mentioned
67299J3398C9399H35.50H35.52H35.54
Original notice
Gene Therapy for Inherited Retinal Dystrophy
bcbsms.com · Always check the source before changing claims.
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