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Local Coverage Determination (LCD)

Voretigene Neparvovec-rzyl (Luxturna®)

L37863

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Document Information

Source LCD ID
N/A
LCD ID
L37863
Original ICD-9 LCD ID
Not Applicable
LCD Title
Voretigene Neparvovec-rzyl (Luxturna®)
Proposed LCD in Comment Period
N/A
Source Proposed LCD
DL37863
Original Effective Date
For services performed on or after 05/06/2019
Revision Effective Date
For services performed on or after 04/20/2023
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
03/21/2019
Notice Period End Date
05/05/2019

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Issue

Issue Description

This LCD outlines limited coverage for this service with specific details under Coverage Indications, Limitations and/or Medical Necessity.
Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, §1862(a)(1)(D) refers to limitations on items or devices that are investigational or experimental.

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §50 Drugs and Biologicals

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

This Local Coverage Determination (LCD) addresses limited indications of the gene therapy, voretigene neparvovec-rzyl (Luxturna®). Voretigene neparvovec-rzyl will be considered reasonable and necessary for the following inherited retinal degenerations with confirmed biallelic RPE65 mutations:

  • Retinitis pigmentosa
  • Leber congenital amaurosis

This limited coverage of voretigene neparvovec-rzyl (Luxturna®) allows for a single dose (1.5x 1011 vector genomes) per eligible eye, per lifetime in beneficiaries who meet all of the coverage indications and documentation requirements as outlined in this LCD. Additionally, coverage is limited to manufacturer-designated Centers of Excellence with expertise in heritable retinal degenerations when performed by qualified vitreoretinal surgeons with evidence of completion of the manufacturer’s surgical and pharmacy training program for the appropriate storage, handling, and administration of voretigene neparvovec-rzyl (Luxturna®).
Summary of Evidence

Voretigene neparvovec-rzyl (Luxturna®) is a gene therapy product approved by the United States (U.S.) Food and Drug Administration (FDA) on December 19, 2017 for treatment of vision loss due to certain heritable retinal dystrophies in patients with confirmed biallelic RPE65 mutations. Specifically, biallelic RPE65 mutation-associated retinal dystrophy is responsible for 2% of cases of autosomal recessive retinitis pigmentosa (RP) and 8-16% of cases of Leber congenital amaurosis (LCA), both of which are phenotypically and genotypically heterogeneous conditions associated with progressive loss of vision, typically presenting at birth or in early childhood-adolescence. The RPE65 gene codes for an enzyme expressed in the retinal pigment epithelium (RPE) that is essential to the visual cycle. The RPE65 mutation results in an inability to regenerate 11-cis retinal, a vitamin A-derived chromophore, which effectively renders rods incapable of responding to light and eventual degeneration of the RPE and photoreceptors.

Using an adeno-associated viral vector, a normal copy of the RPE65 gene is transfected to defective RPE cells by injection of voretigene neparvovec-rzyl into the subretinal space of the macula via a standard 3-port vitrectomy operation in a surgical suite under controlled aseptic conditions in the outpatient setting. The injection is followed by an air-fluid exchange. Post-operative supine head positioning is maintained as much as possible for the first 24 hours. Following treatment of the first eye, the contralateral eye is treated sequentially within a period of 6 to 18 days. A 7-day course of oral prednisone (1 mg/kg/d; max of 40 mg/d) is started 3 days prior to injection, then tapered. 

A Phase 1 open-label, dose escalation study in 12 subjects (aged 8-44 years) with biallelic RPE65 mutation-associated retinal dystrophy was performed to assess safety and efficacy of voretigene neparvovec-rzyl (Study 101). Subjects underwent monocular treatment with either a low (1.5x1010), medium (4.8x1010), or high dose (1.5x1011) vector genome of voretigene neparvovec-rzyl in a 1:2:1 ratio. No dose response effects on safety or preliminary measures of efficacy were observed.  

The contralateral eye of subjects in Study 101 underwent subretinal injection of voretigene neparvovec-rzyl at the high dose (1.5x1011 vector genomes) in a Phase I follow-on study (Study 102). The treatments occurred between 1.7 to 4.6 years following injection of the first eye in 11 of the 12 subjects; 1 subject was excluded due to elevated intraocular pressure prior to undergoing treatment. Improvements over baseline in light sensitivity, navigational ability, and visual acuity were observed in the majority of subjects.  

A Phase 3 open-label, randomized, control crossover trial in 31 subjects (aged 4-44 years; 20 of which were under 18) with biallelic RPE65 LCA was conducted to assess efficacy in improving visual function. Subjects were randomized (2:1) to undergo subretinal voretigene neparvovec-rzyl (1.5x1011 vector genomes) subretinal injections in both eyes versus control (Study 301) and followed for 1 year. The control group did not undergo treatment or sham injection. In total, there were 20 subjects in the bilateral treatment group and 9 subjects serving as controls; 2 subjects withdrew prior to intervention. The average age of the treatment group was 15.9 years and 15.1 years for the control group. At the end of the first year, all 9 control group patients crossed over to undergo bilateral, sequential subretinal injections of voretigene neparvovec-rzyl (Study 302) within 6 to 18 days apart in accordance with the same protocol for Study 301. This was the control/intervention group in Study 302.

The primary outcome measure was the monocular change in scored ability at 1 year to navigate an obstacle course called the multi-luminance mobility test (MLMT) under 7 standardized light levels ranging from 1 to 400 lux using both eyes. A change in MLMT score by 2 or greater is considered to be clinically meaningful. Secondary outcome measures were full-field light sensitivity threshold testing (FST) averaged over both eyes, best-corrected visual acuity (averaged over both eyes), and change in MLMT score of the first treated eye at 1 year. Exploratory endpoints included visual field testing with both Goldmann kinetic perimetry and Humphrey static microperimetry, contrast sensitivity testing, pupillary light reflex, and functional vision assessments, which included a questionnaire completed by subjects (or parents of subjects), as well as, an in-home assessment by independent orientation and mobility specialists.

At 1 year, subjects in the treatment arm of Study 301 had a significantly improved bilateral MLMT score from baseline than did those in the control arm of 1.8 (1.1) light levels vs 0.2 (1.0) light levels (95% CI 0.72-2.41, p=0.0013). FST testing was also significant between the treatment and control groups. Visual acuity changes from baseline were not statistically significant between the 2 groups, though there was a trend toward improvement in the treatment group. Changes from baseline of the other secondary endpoints were not statistically significant between the 2 groups. The self-reported questionnaire indicated an improvement in visual function in performing activities of daily living in the treatment group.  

In total, there were 81 eyes of 41 subjects that underwent treatment with voretigene neparvovec-rzyl in the Phase 1 and Phase 3 studies. Of these, ocular adverse reactions occurred in 46 eyes of 27 subjects and included conjunctival hyperemia, cataract formation, increased intraocular pressure, retinal tears, dellen, macular hole, intraocular inflammation, macular breaks, transient subretinal deposits, irritation pain, and maculopathies. There were 2 serious adverse reactions, 1 case of endophthalmitis with subsequent complications resulting in loss of vision, and 1 case of vision loss due to foveal thinning. 

Durability of response

Earlier studies by independent investigators using RPE65 gene therapies for the same indicated population found similar initial improvement in mobility testing and retinal light sensitivity testing, though the effects were not sustained beyond 3 years. The current study has reported a sustained effect for 2 years (Phase 3) and 3 years (Phase 1); however, long-term efficacy and safety are unknown. 
Analysis of Evidence (Rationale for Determination)

Based on the evidence from the Phase I and Phase III trials, voretigene neparvovec-rzyl has been found to clinically improve functional vision in patients with the biallelic mutations in the RPE65 gene in the inherited retinal degenerations, RP and LCA. In summary, Palmetto GBA considers a single treatment per eye, per lifetime of voretigene neparvovec-rzyl (Luxturna®) medically reasonable and necessary for the treatment of beneficiaries with confirmed biallelic RPE65 mutation-associated subtypes of RP or LCA, who otherwise meet all of the clinical criteria as outlined in this LCD.

Proposed Process Information

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This request was MAC initiated.
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Coding Information

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ICD-10-CM Codes that Support Medical Necessity

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 Group 1 Codes:

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ICD-10-CM Codes that DO NOT Support Medical Necessity

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 Group 1 Codes:

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Additional ICD-10 Information

General Information

Associated Information

Documentation Requirements

Documentation requirements shall include all of the following:

  • Clinical documentation confirming diagnosis of LCA or RP including clinical features, funduscopic appearance, and results of testing such as dark-adapted thresholds, Ganzfeld-flash electroretinography (ERG), and when appropriate, perimetry. When performed, documentation of baseline (pre-treatment) white light FST per eye and baseline (pre-treatment) MLMT score should also be included.
  • Documentation of a positive genetic test result confirming a biallelic pathogenic or likely pathogenic RPE65 mutation (homozygote or compound heterozygote) by a MolDX-approved mutational test. Genetic testing showing the presence of a homozygous pathogenic mutation will be considered to meet this requirement. All results demonstrating 2 different pathogenic or likely pathogenic mutations on the RPE65 gene must be accompanied by segregation analysis results confirming biallelic involvement (trans configuration). A single heterozygous RPE65 mutation cannot be biallelic. Patients with 2 pathogenic or likely pathogenic mutations involving only 1 copy of the RPE65 gene (cis configuration) are excluded from coverage. If segregation analysis is not possible (e.g., in cases of adoption, absence of surviving biologic family members relevant for testing, refusal of genetic testing by relevant biological family members), the treating physician must determine that:
    • The genetic sequencing test results match the patient's phenotype with a high degree of specificity based on the scientific literature related to RPE65, and,
    • Other pathogenic variants associated with the patient's phenotype have been ruled out or deemed less likely than biallelic RPE65 mutation-associated disease.
  • Age > 3 years
  • Confirmation of sufficient viable photoreceptors in each eye planned for treatment by both ophthalmoscopy and 1 or more of the following:
    • Optical coherence tomography (OCT) thickness >100 um with presence of neural retina in the posterior pole
    • > 3 disc areas of retina free of atrophy and/or pigmentary degeneration in the posterior pole
    • Intact visual field within 30° of fixation as measured by a III4e isopter or equivalent.
  • Documentation of clinical presentation, duration of symptoms, progression, and any prior interventions including current visual function and supportive care management.
  • Beneficiary must have no history of participation in a gene therapy study or treatment with voretigene neparvovec-rzyl or other similar or dissimilar gene therapy product prior to treatment of the first eye.
Sources of Information
N/A
Bibliography

Bennett J, Wellman J, Marshall KA, et al. Safety and durability of effect of contralateral-eye administration of AAV2 gene therapy in patients with childhood-onset blindness caused by RPE65 mutations: A follow-on phase 1 trial. Lancet. 2016;388:661-72. 

Chung DC, McCague S, Zi-Fan Y, et al. Novel mobility test to assess functional vision in patients with inherited retinal dystrophies. Clin Exp Ophthalmol. 2017;1-13.

Maguire AM, High KA, Auricchio A, et al. Age-dependent effects of RPE65 gene therapy for Leber’s congenital amaurosis: A phase 1 dose-escalation trial. Lancet. 2009;374:1597-1605.

Maguire AM, Simonelli F, Pierce EA, et al. Safety and efficacy of gene transfer for Leber’s congenital amaurosis. N Engl J Med. 2008;358(21):2240-2248.

Russell S, Bennett J, Wellman JA, et al. Efficacy and safety of voretigene neparvovec (AAV2-hRPE65v2) in patients with RPE65-mediated inherited retinal dystrophy: A randomised, controlled, open-label, phase 3 trial. Lancet. 2017;390:849-860.

Simonelli F, Maguire AM, Testa F, et al. Gene therapy for Leber’s congenital amaurosis is safe and effective through 1.5 years after vector administration. Mol Ther. 2010;18(3):643-650.

Spark Therapeutics. (2017). LUXTURNA®: Highlights of Prescribing Information. Philadelphia, PA: Author.

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
04/20/2023 R6

Under CMS National Coverage Policy deleted regulation “CMS Manual System, Pub. 100-04, Medicare Claims Processing Manual, Change Request 10781, Transmittal 4064, dated Jun 1, 2018” and added regulation “CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §50 Drugs and Biologicals.” Under Bibliography deleted reference for the FDA Advisory Committee Transcript as it is no longer accessible, and changes were made to citations to reflect AMA citation guidelines. Formatting, punctuation and typographical errors were corrected throughout the LCD.
  • Provider Education/Guidance
05/28/2020 R5

Under LCD Title changes were made to remove trademark and add registered mark. Under Bibliography changes were made to update FDA hyperlinks. Formatting, punctuation and typographical errors were corrected throughout the LCD. Acronyms were inserted where appropriate throughout the LCD. Luxturna® was added where applicable throughout the LCD. 

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.
  • Provider Education/Guidance
10/24/2019 R4

This LCD is being revised in order to adhere to CMS requirements per chapter 13, section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs. There has been no change in coverage with this LCD revision. Regulations regarding billing and coding were removed from the CMS National Coverage Policy section of this LCD and placed in the related Billing and Coding: Voretigene Neparvovec-rzyl (Luxturna™) A56419 article. Under Bibliography changes were made to citations to reflect AMA citation guidelines.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

 
  • Provider Education/Guidance
09/05/2019 R3

Under Contract Number removed contract 11004 as it was inadvertently added with Revision 1. Under Coding Information: Bill Type Codes removed code 022x as it was inadvertently added with Revision 1.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.
  • Provider Education/Guidance
05/06/2019 R2

Under Documentation Requirements, second bullet, the verbiage has been changed to, “Documentation of a positive genetic test result confirming a biallelic pathogenic or likely pathogenic RPE65 mutation (homozygote or compound heterozygote) by a MolDX-approved mutational test. Genetic testing showing the presence of a homozygous pathogenic mutation will be considered to meet this requirement. All results demonstrating two different pathogenic or likely pathogenic mutations on the RPE65 gene must be accompanied by segregation analysis results confirming biallelic involvement (trans configuration). A single heterozygous RPE65 mutation cannot be biallelic. Patients with two pathogenic or likely pathogenic mutations involving only one copy of the RPE65 gene (cis configuration) are excluded from coverage. If segregation analysis is not possible (e.g. in cases of adoption, absence of surviving biologic family members relevant for testing, refusal of genetic testing by relevant biological family members), the treating physician must determine that:

  • the genetic sequencing test results match the patient’s phenotype with a high degree of specificity based on the scientific literature related to RPE65, and,
  • other pathogenic variants associated with the patient’s phenotype have been ruled out or deemed less likely than biallelic RPE65 mutation-associated disease.

The fifth bullet which read, "Best corrected visual acuity worse than 20/60 or visual field < 20° in any meridian of each eye (pre-treatment baseline") has been deleted.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.
  • Provider Education/Guidance
05/06/2019 R1

All coding located in the Coding Information section has been moved into the related Billing and Coding for Voretigene Neparvovec-rzyl (Luxturna™) A56419 article and removed from the LCD.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

 
  • Provider Education/Guidance
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Keywords

  • Luxturna
  • Voretigene Neparvovec-rxyl

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