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This is a new policy published on 6/25/2019. It will be effective on 7/27/2019 or later.
  
Horizon BCBSNJ
Uniform Medical Policy ManualSection:Drugs
Policy Number:193
Effective Date: 07/27/2019
Original Policy Date:06/25/2019
Last Review Date:
Date Published to Web: 06/25/2019
Subject:
Onasemnogene Abeparvovec (Zolgensma)

Description:
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IMPORTANT NOTE:

The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.

Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.

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Spinal Muscular Atrophy (SMA) disorders are characterized by degeneration of the anterior horn cells in the spinal cord and motor nuclei in the lower brainstem. These diseases are classified as types 1 through 4 depending upon the age of onset and clinical course. The incidence of spinal muscular atrophy ranges from 4 to 10 per 100,000 live births, and the carrier frequency of disease-causing SMN1 mutations ranges from 1/90 to 1/50.

Zolgensma (onasemnogene abeparvovec) is an adeno-associated virus vector-based gene therapy indicated for the treatment of pediatric patient less than 2 years of age with spinal muscular atrophy (SMA) with bi-allelic mutations in the survival neuron 1 (SMN1) gene. Zolgensma (onasemnogene abeparvovec) is a one-time intravenously administered drug that delivers a copy of SMN in a self-complementary adeno-associated viral serotype 9 (scAAV9).

The efficacy of Zolgensma (onasemnogene abeparvovec) in pediatric patients less than 2 years of age with SMA with bi-allelic mutations in the SMN1 gene was evaluated in an open-label, single-arm clinical trial (ongoing) and an open-label, single-arm, ascending-dose clinical trial (completed). Patients experienced onset of clinical symptoms consistent with SMA before 6 months of age. All patients had genetically confirmed bi-allelic SMN1 gene deletions, 2 copies of the SMN2 gene, and absence of the c.859G>C modification in exon 7 of SMN2 gene (which predicts a milder phenotype). All patients had baseline anti-AAV9 antibody titers of ≤ 1:50, measured by ELISA.

In both trials, Zolgensma (onasemnogene abeparvovec) was delivered as a single-dose intravenous infusion. Efficacy was established on the basis of survival, and achievement of developmental motor milestones such as sitting without support. Survival was defined as time from birth to either death or permanent ventilation. Permanent ventilation was defined as requiring invasive ventilation (tracheostomy), or respiratory assistance for 16 or more hours per day (including noninvasive ventilatory support) continuously for 14 or more days in the absence of an acute reversible illness, excluding perioperative ventilation. Efficacy was also supported by assessments of ventilator use, nutritional support and scores on the Children's Hospital of Philadelphia Infant Test of Neuromuscular Disorders (CHOP-INTEND). CHOP-INTEND is an assessment of motor skills in patients with infantile-onset SMA

As of the March 2019 data cutoff, 19 patients were alive without permanent ventilation (i.e., event-free survival) and were continuing in the trial, while one patient died at age 7.8 months due to disease progression, and one patient withdrew from the study at age 11.9 months. The 19 surviving patients who were continuing in the trial ranged in age from 9.4 to 18.5 months. By the data cutoff, 13 of the 19 patients continuing in the trial reached 14 months of age without permanent ventilation, one of the study’s co-primary efficacy endpoints. In addition to survival, assessment of the other co-primary efficacy endpoint found that 10 of the 21 patients (47.6%) achieved the ability to sit without support for ≥ 30 seconds between 9.2 and 16.9 months of age (mean age was 12.1 months). Based on the natural history of the disease, patients who met the study entry criteria would not be expected to attain the ability to sit without support, and only approximately 25% of these patients would be expected to survive (i.e., being alive without permanent ventilation) beyond 14 months of age. In addition, 16 of the 19 patients had not required daily NIV use.

The completed clinical trial enrolled 15 patients (6 male and 9 female) with infantile-onset SMA, 3 in a low-dose cohort and 12 in a high-dose cohort. At the time of treatment, the mean age of patients in the low-dose cohort was 6.3 months (range 5.9 to 7.2 months), and 3.4 months (range 0.9 to 7.9 months) in the high-dose cohort. The dosage received by patients in the low-dose cohort was approximately one-third of the dosage received by patients in the high-dose cohort. By 24 months following Zolgensma infusion, one patient in the low-dose cohort met the endpoint of permanent ventilation; all 12 patients in the high-dose cohort were alive without permanent ventilation. None of the patients in the low-dose cohort were able to sit without support, or to stand or walk; in the high-dose cohort, 9 of the 12 patients (75.0%) were able to sit without support for ≥ 30 seconds, and 2 patients (16.7%) were able to stand and walk without assistance.

The most common adverse reactions (incidence ≥ 5%) were elevated aminotransferases and vomiting.

As per the FDA approved package insert Zolgensma (onasemnogene abeparvovec) carries a Black Box Warning for acute serious liver injury and elevated aminotransferases. Patients with pre-existing liver impairment maybe at a higher risk. Prior to infusion, access liver function of all patients by clinical examination and laboratory testing(e.g, hepatic aminotransferases[aspartate aminotransferase(AST) and alanine aminotransferase (ALT) ], total bilirubin and prothrombin time). Administer a systemic corticosteroid to all patients before and after Zolgensma (onasemnogene abeparvovec) infusion. Continue to monitor liver function for at least 3 months after infusion.


Policy:
I. Zolgensma (onasemnogene abeparvovec) is medically necessary for the treatment of pediatric patients less than 9 months of age with spinal muscular atrophy (SMA) when all of the following criteria are met:


    A. The patient has a confirmed genetic diagnosis of SMA type I as documented by the following:
        • Patient has a bi-allelic SMN1 5q gene variants or deletions, and

        • Patient has 2 or fewer copies of the SMN2 gene AND

    B. Onset of SMA-associated signs and symptoms before 6 months of age AND

      [INFORMATIONAL NOTE: Based on the inclusion criteria of the two clinical trials that are listed in the Zolgensma FDA package labeling, patients that received the drug were limited to up to 6 months of age to a maximum of 9 months of age or younger. Inclusion criteria for the START trial (NCT02122952) stated patients were 6 or 9 months of age and younger on day of infusion. Inclusion criteria for the STR1VE trial (NCT03306277) stated patients must have been <6 months of age at time of infusion.]
    C. Documentation of anti-adeno-associated virus serotype 9 antibody titer ≤1:50 AND

    D. Patient does not have advanced SMA (e.g., complete paralysis of limbs or permanent ventilator dependence) AND

    E. Documentation of baseline platelet counts, troponin-I, AST/ALT/bilirubin levels/prothrombin time AND

    F. Patient has not previously received a gene therapy for SMA or is not concurrently enrolled in a clinical trial for any experimental therapy for SMA AND

    G. Patient has not previously received Spinraza (nusinersen) AND


      [INFORMATIONAL NOTE: All patients enrolled in clinical trials had not received any therapy (including Spinraza) prior to using Zolgensma. 3 out of 10 patients in the long-term follow up study did use Spinraza at least 2 years after Zolgensma, however no clinical benefit was seen these patients compared to those that used Zolgensma alone.]

    H. Baseline documentation of at least one of the following:
        • Patient’s weight in those who are without gastrostomy tube

        • Motor function/milestones, as shown in the Hammersmith Infant Neurologic Exam (HINE) Hammersmith Functional Motor Scale Expanded (HFMSE), 6-minute walk test (6MWT), upper limb nodule (ULM), CHOP-INTEND

        • Respiratory function test such as forced vital capacity

        • Patient has exacerbations requiring hospitalization and/or antibiotic therapy for respiratory infection within the prior year


      [INFORMATIONAL NOTE: The HINE Exam evaluates seven different areas of motor milestone development, with a maximum score between 2-4 points for each, depending on the milestone, and a total maximum score of 26. A treatment responder was defined as any patient with at least a 2-point increase (or maximal score of 4) an ability to kick (consistent with improvement by at least 2 milestones), or at least a 1-point increase in the motor milestones of head control, rolling, sitting, crawling, standing or walking (consistent with improvement by at least 1 milestone. To be classified as a responder, patients needed to exhibit improvement in more categories of motor milestones; 6MWT an objective evaluation of functional exercise capacity that measures the maximum distance a person can walk in 6 minutes over a 25-meter linear course; ULM is an outcome measure specifically developed to assess upper limb functional abilities in patients with SMA, including young children and patients with severe contractures in the lower limbs, in whom the possibility to detect functional changes, such as rolling or long sitting, is limited; CHOP-INTEND measures motor function via 16 different items, which capture neck, trunk, proximal and distal limb strength. Scored from 0 (least function) to 4 (most function) for each of the 16 items.]
II. When Zolgensma (onasemnogene abeparvovec) is considered medically necessary, therapy will be approved once per lifetime based on FDA-approved labeling:
      A. 1.1 x 10^14 vector genomes per kilogram (vg/kg) of body weight as a one-time infusion

        As per the FDA package insert: See table 1 - Dosing Table

        Table 1: Dosing

        Patient Weight Range (kg)Dose Volume (mL)
        2.6 - 3.016.5
        3.1 - 3.519.3
        3.6 - 4.022.0
        4.1 - 4.524.8
        4.6 - 5.027.5
        5.1 - 5.530.3
        5.6 - 6.033.0
        6.1 - 6.535.8
        6.6 - 7.038.5
        7.1 - 7.541.3
        7.6 - 8.044.0
        8.1 - 8.546.8
        8.6 - 9.049.5
        9.1 - 9.652.3
        9.6 - 10.055.0
        10.1 - 10.557.8
        10.6 - 11.060.5
        11.1 - 11.563.3
        11.6 - 12.066.0
        12.1 - 12.568.8
        12.6 - 13.071.5
        13.1 - 13.574.3
a. Dose volume is calculated using the upper limit of the patient weight range for pediatric patients less than 2 years of age between 2.6 kg and 13.5 kg
b. Dose volume for pediatric patients less than 2 years of age weighing equal to or greater than 13.6 kg will require a combination of ZOLGENSMA kits
    [INFORMATIONAL NOTE: The safety and efficacy of repeat administration of Zolgensma (onasemnogene abeparvovec) have not been evaluated.

    As per the FDA approved package insert, monitor liver function by clinical examination and by laboratory testing on a regular basis. One day prior to Zolgensma infusion, begin administration of systemic corticosteroids equivalent to oral prednisolone at 1 milligram per kilogram of body weight per day (mg/kg/day) for a total of 30 days. At the end of the 30-day period of systemic corticosteroid treatment, check liver status clinically and by assessing ALT, AST, total bilirubin, and prothrombin time. For patients with unremarkable findings (normal clinical exam, total bilirubin, and prothrombin time, and ALT and AST levels below 2 × upper limit of normal (ULN)), taper the corticosteroid dose over the next 28 days. If liver function abnormalities persist, continue systemic corticosteroids (equivalent to oral prednisolone at 1 mg/kg/day) until AST and ALT values are both below 2 × ULN and all other assessments return to normal range, and then taper the corticosteroid dose over the next 28 days.]


III. Other uses of Zolgensma (onasemnogene abeparvovec) are considered investigational, including but not limited to, other types of SMA besides SMA type 1, asymptomatic SMA, etc.

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Horizon BCBSNJ Medical Policy Development Process:

This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.

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Index:
Onasemnogene Abeparvovec (Zolgensma)
Zolgensma (Onasemnogene Abeparvovec)

References:
1. Single-Dose Gene-Replacement Therapy for Spinal Muscular Atrophy N Engl J Med 2017;377:1713-22. DOI: 10.1056/NEJMoa1706198

2. Zolgensma [package insert]. Bannockburn, IL: AveXis, Inc.; May 2019.

3. Zolgensma. Clinicaltrial.gov. Accessed on 5/22/19 . Available at: https://clinicaltrials.gov/ct2/show/NCT02122952

4. Zolgensma. Clinicaltrial.gov. Accessed on 5/22/19 . Available at: https://clinicaltrials.gov/ct2/show/NCT03306277

5. Spinal Muscular Atrophy 1 | Genetic And Rare Diseases Information Center (GARD). Rarediseases.Info.Nih.Gov, 2019, https://rarediseases.info.nih.gov/diseases/7883/spinal-muscular-atrophy-1.

6. Arnold, W David et al. “Spinal muscular atrophy: diagnosis and management in a new therapeutic era.” Muscle & nerve vol. 51,2 (2015): 157-67. doi:10.1002/mus.24497

7. Prior TW, Finanger E. Spinal Muscular Atrophy. 2000 Feb 24 [Updated 2016 Dec 22]. In: Adam MP, Ardinger HH, Pagon RA, et al., editors. GeneReviews® [Internet]. Seattle (WA): University of Washington, Seattle; 1993-2019. Available from: https://www.ncbi.nlm.nih.gov/books/NBK1352/

Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)

CPT*

    HCPCS


    * CPT only copyright 2019 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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    Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.

    The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy

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