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Acthar Gel (repository corticotropin injection) — United Healthcare

Opsoclonus-myoclonus syndrome (Kinsbourne Syndrome)

Initial criteria

  • Diagnosis of opsoclonus-myoclonus syndrome (Kinsbourne Syndrome)

Reauthorization criteria

  • All requests for reauthorization will be denied; continuation must be submitted through the appeals process.

Approval duration

3 months