Summary
Aetna's Clinical Policy Bulletin 0810 for gout applies to commercial medical plans and was last reviewed 03/27/2026. Pegloticase (Krystexxa) is covered for chronic gout in members 18 or older who meet the initial approval criteria, and for continuing therapy when the continuation criteria are met. Oral urate-lowering therapy cannot be used at the same time as pegloticase. The Site of Care Utilization Management Policy applies to pegloticase beginning January 1, 2026. Pegloticase is considered experimental, investigational, or unproven for all other indications, including asymptomatic hyperuricemia and G6PD deficiency. Blood uric acid measurement, erythrocyte sedimentation rate, polarized light microscopy of synovial fluid, and MRI for gouty tophus are considered medically necessary for managing gout.
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