Sucraid (sacrosidase) — Highmark

Initial criteria

• age ≥ 5 months
• diagnosis of congenital sucrase-isomaltase deficiency (ICD-10: E74.31)
• clinical documentation supporting CSID diagnosis with ONE of the following:
• 1. Small bowel biopsy with disaccharidase assay demonstrating ALL of the following: absent or reduced sucrase activity AND reduced or normal isomaltase activity AND reduced maltase activity AND reduced or normal lactase activity
• OR 2. Genetic testing indicates a mutation in the sucrase-isomaltase (SI) gene
• OR 3. Member meets ALL of the following: stool pH < 6 AND negative lactose breath test AND sucrase deficiency evidenced by EITHER sucrose breath hydrogen test with increase in breath hydrogen > 10 ppm after sucrose challenge OR 13C-sucrose breath test CO exhalation over 90 minutes below 10th percentile (< 3.91% for men, < 5.10% for women)

Reauthorization criteria

• prescriber attests that the member has experienced positive clinical response to therapy

Approval duration

12 months