Background

Exagamglogene autotemcel (Casgevy™) is a genetically modified autologous CD34+ cell enriched population that contains human hematopoietic stem and progenitor cells edited ex vivo by CRISPR/Cas9 at the erythroid-specific enhancer region of the BCL11A gene.

Exagamglogene autotemcel (Casgevy) works by increasing the production of a special type of hemoglobin called fetal hemoglobin (HbF). Having more fetal hemoglobin increases hemoglobin levels in the body and improves the production and function of red blood cells.

Policy

Exagamglogene autotemcel is considered medically necessary for individuals when ALL of the following are met:

• Submission of medical records (e.g., chart notes) documenting confirmed diagnosis of sickle cell disease with ONE of the following genotypes:
  • βS/βS
  • βS/β0
  • βS/β+

NOTE: Additional genotypes will be considered on an individual consideration (IC) basis based on disease severity.

• Age 12 years or older
• Prescriber is a specialist at a qualified treatment center for Casgevy
• Patient does not have a contraindication to the prescribed medication
• Submission of medical records (e.g., chart notes) documenting patient has history of intolerance or failure of hydroxyurea treatment OR patient use of hydroxyurea is contraindicated (per provider clinical judgement)
• Submission of medical records (e.g., chart notes), provider attestation, documenting that prior to treatment, patient has experienced at least 2 (two) severe vaso-occlusive crises in the past 24 months OR is currently receiving chronic red blood cell (RBC) transfusion therapy for the prevention of severe vaso-occlusive episodes

NOTE: Severe VOC is defined as an occurrence of at least one of the following events requiring an evaluation at a medical facility with no medically determined cause other than vaso-occlusion requiring administration of pain medications such as opioids or intravenous (IV) non-steroidal anti-inflammatory drugs (NSAIDs) or RBC transfusions:

• Acute pain
• Acute chest syndrome
• Acute hepatic sequestration
• Priapism > 2 hours
• Splenic sequestration

• Patient has a negative serologic test for HIV infection

Length of Authorization:	One treatment course (12 months)
Renewal Criteria:	Not applicable as no further authorizations will be provided

 

References

1. Casgevy™ (exagamglogene autotemcel) suspension, for intravenous infusion [package insert]. Vertex Pharmaceuticals, Inc. Boston, MA. Revised 12/2023.
2. Clinical PharmacologyTM Compendium. 2023. Tampa FL: Gold Standard, Inc. Exagamglogene autotemcel.
3. Micromedex DrugDex Compendium®. 2023. Exagamglogene autotemcel.

 

Coding Section

Code	Number	Description
HCPCS	J3590	Unclassified biologics

 

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

History From 2024 Forward

06/01/2025	Interim review, Clarifications to treatment course (12 months) and additional revisions as requested.
04/01/2025	interim review, Updated “patient experienced at least four vaso-occulisive crises” to at last two vaso-occlusive crises.
02/21/2025	Annual review, no changes to policy intent.
11/01/2024	New Policy