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nintedanib — Blue Cross Blue Shield of Alabama

chronic fibrosing interstitial lung disease (ILD) with a progressive phenotype

Initial criteria

  • ONE of the following:
  • Diagnosis of idiopathic pulmonary fibrosis (IPF) AND all of the following: other known causes of ILD excluded (e.g., domestic and occupational environmental exposures, connective tissue diseases, drug toxicities, alternative diagnoses, etc); AND ONE of: HRCT scan showing usual interstitial pneumonia (UIP); OR surgical lung biopsy confirming UIP; OR HRCT scan showing probable UIP and surgical lung biopsy indicating probable UIP
  • OR diagnosis of systemic sclerosis-associated interstitial lung disease (SSc-ILD) AND all of the following: diagnosis confirmed on HRCT or chest radiography; AND ONE of: tried and had inadequate response to ONE conventional agent (e.g., mycophenolate mofetil, cyclophosphamide, azathioprine); OR intolerance or hypersensitivity to ONE conventional agent; OR FDA labeled contraindication to ALL conventional agents
  • OR diagnosis of chronic fibrosing interstitial lung disease (ILD) with a progressive phenotype AND BOTH of the following: [criteria continue in policy]