nintedanib — Blue Cross Blue Shield of Montana

Initial criteria

• Diagnosis of idiopathic pulmonary fibrosis (IPF) AND exclusion of other known causes of interstitial lung disease (e.g., environmental exposures, connective tissue disease, drug toxicity)
• Diagnostic confirmation with high-resolution computed tomography (HRCT) or surgical lung biopsy showing usual interstitial pneumonia (UIP) or probable UIP pattern