Aetna considers afamelanotide (Scenesse) medically necessary for biochemically confirmed erythropoietic protoporphyria in adult members whose protoporphyrin level is above the lab reference range in peripheral red blood cells. Aetna considers continuation of afamelanotide therapy medically necessary for adult members with that indication who are experiencing benefit from therapy while receiving it. Aetna considers all other indications experimental, investigational, or unproven, including inhibition of drug-resistant pathogenic bacteria such as MRSA and treatment of acute ischemic stroke, and this policy applies to commercial medical plans.
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01Billing team: Bill HCPCS J7352 (afamelanotide implant, 1 mg) for ICD-10 E80.0 (hereditary erythropoietic porphyria) when the selection criteria are met.
02ICD-10 codes A49.02 (methicillin resistant Staphylococcus aureus infection, unspecified site) and I63.9 (cerebral infarction, unspecified) are listed as not covered for the indications in the policy.
03For continuation, the member must be experiencing benefit from therapy while receiving afamelanotide.
04The implant must be administered by a healthcare professional who is proficient in the subcutaneous implantation procedure and has completed training, as a single 16 mg implant inserted subcutaneously above the anterior supra-iliac crest every 2 months using an SFM Implantation Cannula.
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