Clinical UM Guideline

Subject:Beta Interferons or Glatiramer Acetate for Treatment of Multiple Sclerosis
Guideline #:  CG-DRUG-03Current Effective Date:  10/12/2011
Status:ReviewedLast Review Date:  08/18/2011
Description

A number of drugs are available to treat various aspects of multiple sclerosis (MS). Interferon beta agents (i.e., Avonex®, Biogen Idec, Inc., Cambridge, MA; Rebif®, EMD Serono, Inc., Rockland, MA; Betaseron®, Bayer HealthCare Pharmaceuticals Inc., Montville, NJ; Extavia®, Novartis Pharmaceuticals Corp., East Hanover, New Jersey), and glatiramer acetate (Copaxone®, TEVA Neuroscience, Inc., Kansas, MO) are administered in an effort to decrease the relapse rate and delay the progression of the disease. For the majority of individuals with MS, the mainstay of treatment focuses on the use of interferon beta (IFN-B) agents or glatiramer acetate. This guideline focuses on the use of IFN beta-1a (Avonex, Rebif), IFN beta-1b (Betaseron, Extavia) and glatiramer acetate (Copaxone) for the treatment of MS.

Clinical Indications

I. Beta Interferons (IFN beta-1a [Avonex, Rebif] or IFN beta-1b [Betaseron, Extavia]) 

Medically Necessary:

Treatment of MS with IFN beta-1a or IFN beta-1b is considered medically necessary for individuals with any of the following conditions:

Not Medically Necessary:

Treatment of MS with IFN beta-1a or IFN beta-1b is considered not medically necessary for individuals with either of the following conditions:

Treatment of MS with IFN beta-1a or IFN beta-1b in combination with glatiramer acetate or in combination with natalizumab is considered not medically necessary for all conditions.

II. Glatiramer acetate (Copaxone) 

Medically Necessary: 

Treatment of MS with glatiramer acetate is considered medically necessary for individuals with relapsing-remitting MS (RRMS), including those who have experienced a first clinical episode and have MRI features consistent with MS.

Not Medically Necessary:

Treatment of MS with glatiramer acetate is considered not medically necessary for individuals with either of the following conditions:

Treatment of MS with glatiramer acetate in combination with any IFN-B agent or in combination with natalizumab is considered not medically necessary for all conditions.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

HCPCS 
J1595Injection, glatiramer acetate, 20 mg (Copaxone)
J1826Injection, interferon beta-1a, 30 mcg (Avonex, Rebif)
J1830Injection, interferon beta-1b, 0.25 mg (Betaseron, Extavia)
Q3025Injection, interferon beta-1a, 11 mcg for intramuscular use (Avonex, Rebif)
Q3026Injection, interferon beta-1a, 11 mcg for subcutaneous use (Avonex, Rebif)
S9559Home injectable therapy, interferon, including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment; per diem
  
ICD-9 Diagnosis 
340Multiple sclerosis

Future ICD-10 coding (effective 10/01/2013)
A draft of ICD-10 Coding related to this document, as it might look today, is available for reference and comments at: Appendix 1: Future ICD-10 coding

Discussion/General Information

MS is an autoimmune disease of the central nervous system (CNS). In MS, inflammation of nervous tissue causes the loss of myelin, a fatty material that acts as a protective insulation for the nerve fibers in the brain and spinal cord. This demyelination leaves multiple areas of hard scarred tissue (plaques) along the covering of the nerve cells. Another characteristic of MS is the destruction of axons, which are the long filaments that carry electric impulses away from a nerve cell. The demyelination and axon destruction disrupts the ability of the nerves to conduct electrical impulses to and from the brain, and produces the various symptoms. Common symptoms of the disease include fatigue, numbness, coordination and balance problems, bowel and bladder dysfunction, emotional and cognitive changes, spasticity, vision problems, dizziness, sexual dysfunction, and pain. Classifications of MS are relapsing remitting (RRMS), primary progressive (PPMS), progressive relapsing (PRMS), and secondary progressive MS (SPMS). Most individuals with MS have a relapsing course and their first attack may present as a clinically isolated syndrome (CIS). A CIS is a single demyelinating episode with consistent MRI findings (indicating inflammation/demyelination in one or more sites in the CNS). Individuals with this syndrome are at high risk for developing clinically definite MS.

The treatment goal for MS is to prevent relapses and progressive worsening of the disease. To date, a cure remains elusive and current therapies fail to reverse degenerative processes and deficits. Current disease-modifying drugs are most effective for the relapsing-remitting form of MS and less effective for secondary progressive decline. The American Academy of Neurology (AAN), the Multiple Sclerosis Council for Clinical Practice Guidelines and the National Multiple Sclerosis Society suggest starting disease-modifying therapy (drug treatment) in those with relapsing remitting disease and recent relapses; however, opinions may vary widely on when to initiate treatment (AAN, 2002). Generally, disease-modifying therapy should be considered early in the disease course.

IFN beta-1a, IFN beta-1b and glatiramer acetate are all United States Food and Drug Administration (FDA) approved disease-modifying therapies (DMTs). In 1993, the first DMT, IFN beta-1b (Betaseron) was approved for RRMS to reduce the rate and severity of relapses. This was followed by approval of IFN beta-1a (Avonex) in 1996 and glatiramer acetate (Copaxone) in 1997. Another formulation of IFN beta-1a (Rebif) was approved in 1998 in Europe and Canada and in 2002 in the United States. These drugs have been shown to delay the progression of MS, reduce the incidence of relapses and also reduce the MRI activity thought to be linked to the underlying inflammation of the disease (Freedman 2008). In August 2009, the FDA approved Extavia, a new branded version of interferon beta-1b which has the same medicinal product as Betaseron.

IFN beta-1a and IFN beta-1b are FDA approved for relapsing forms of MS. In addition, the efficacy of IFN beta-1a and IFN beta-1b has been demonstrated in individuals who have experienced a first clinical episode and have MRI features consistent with MS. Glatiramer acetate is FDA approved for RRMS and for those who have experienced a first clinical episode and have MRI features consistent with MS.

The AAN (2002) recommends beta interferon (beta 1a and beta 1b) for the management of individuals with RRMS, relapsing forms of secondary progressive MS, and in those with MS or with a CIS who are at high risk of developing clinically definite MS. The AAN (2002) notes that there are several consistent Class I studies (prospective, randomized, controlled clinical trials with masked outcome assessments, in a representative population) in which beta interferon has been demonstrated to reduce the attack rate (whether measured clinically or by MRI) in individuals with MS or with CIS who are at high risk for developing MS (Type A recommendation). A "Type A recommendation" is the highest rating assigned by the AAN.

The National Clinical Advisory Board of the National Multiple Sclerosis Society Treatment Recommendations for Physicians (2008) Expert Opinion Paper states that "there are no direct comparative data to allow a fully informed choice of the best immunomodulatory drug class (interferon beta or glatiramer acetate) with which to initiate therapy in relapsing forms of MS."

Studies have demonstrated the efficacy of the beta interferon products and glatiramer acetate in the treatment of MS (Ford, 2010; Kinkel, 2006; Reder, 2010). However, current data is insufficient to make a recommendation regarding the use of one of the beta interferon products (Avonex, Rebif, Betaseron, and Extavia) over another. Also, the data is insufficient to make a recommendation regarding the use of the beta interferon products (Avonex, Rebif, Betaseron, and Extavia) over glatiramer acetate (Copaxone) in the treatment of RRMS.

Off Label Indications:

Diagnostic criteria for MS have evolved in recent years. Although the diagnosis can be made on clinical grounds alone, MRI of the CNS can support, supplement, or even replace some clinical criteria (Pohlman, 2011). The McDonald Criteria, a tool for the diagnosis of MS, was recently updated in 2010 by the International Panel on Diagnosis of MS (the Panel). The Panel stressed that the McDonald criteria should only be applied in those individuals who present with a typical CIS suggestive of MS or symptoms consistent with a CNS inflammatory demyelinating disease. This is because the development and validation of the criteria was limited to individuals with such a presentation. The 2010 McDonald criteria are documented in the table below and include clinical presentations as well as additional data needed for MS diagnosis including MRI findings for demonstration of dissemination of CNS lesions in space and time.

The 2010 McDonald Criteria for Diagnosis of MS
 (Polman, 2011) 

Clinical Presentation

Additional Data Needed for MS Diagnosis

2 or more attacksa; objective clinical evidence of 2 or more lesions or objective clinical evidence of 1 lesion with reasonable historical evidence of a prior attackb.

Nonec 

 

2 or more attacksa; objective clinical evidence of one lesion

 

Dissemination in space, demonstrated by:

  • 1 or more T2 lesion in at least 2 of 4 MS-typical regions of the CNS (periventricular, juxtacortical, infratentorial, or spinal cord)d; or
  • Await further clinical attacka implicating a different CNS site

1 attacka; objective clinical evidence of two or more lesions

 

Dissemination in time, demonstrated by:

  • Simultaneous presence of asymptomatic gadolinium-enhancing and nonenhancing lesions at any time; or
  • A new T2 and/or gadolinium-enhancing lesion(s) on follow-up MRI, irrespective of its timing with reference to a baseline scan; or
  • Await a second clinical attacka

1 attacka; objective clinical evidence of one lesion (clinically isolated syndrome)

 

Dissemination in space and time, demonstrated by:

For dissemination in space (DIS):

  • 1 or more T2 lesion in at least 2 of 4 MS-typical regions of the CNS (periventricular, juxtacortical, infratentorial, or spinal cord)d;or
  • Await a second clinical attacka implicating a different CNS site; and

For dissemination in time (DIT), demonstrated by:

  • Simultaneous presence of asymptomatic gadolinium-enhancing and nonenhancing lesions at any time; or
  • A new T2 and/or gadolinium-enhancing lesion(s) on follow-up MRI, irrespective of its timing with reference to a baseline scan; or
  • Await a second clinical attacka

Insidious neurological progression suggestive of MS (PPMS)

 

1 year of disease progression (retrospectively or prospectively determined) plus 2 of 3 of the following criteriad:

  1. Evidence for DIS in the brain based on one or more T2 lesions in the MS-characteristic (periventricular, juxtacortical, or infratentorial) regions
  2. Evidence for DIS in the spinal cord based on 2 or more T2 lesions in the cord
  3. Positive CSF (isoelectric focusing evidence of oligoclonal bands and/or elevated IgG index)

 

If the Criteria are fulfilled and there is no better explanation for the clinical presentation, the diagnosis is ''MS''; if suspicious, but the Criteria are not completely met, the diagnosis is ''possible MS''; if another diagnosis arises during the evaluation that better explains the clinical presentation, then the diagnosis is ''not MS.''

aAn attack (relapse; exacerbation) is defined as patient-reported or objectively observed events typical of an acute inflammatory demyelinating event in the CNS, current or historical, with duration of at least 24 hours, in the absence of fever or infection. It should be documented by contemporaneous neurological examination, but some historical events with symptoms and evolution characteristic for MS, but for which no objective neurological findings are documented, can provide reasonable evidence of a prior demyelinating event. Reports of paroxysmal symptoms (historical or current) should, however, consist of multiple episodes occurring over not less than 24 hours. Before a definite diagnosis of MS can be made, at least 1 attack must be corroborated by findings on neurological examination, visual evoked potential response in patients reporting prior visual disturbance, or MRI consistent with demyelination in the area of the CNS implicated in the historical report of neurological symptoms.

bClinical diagnosis based on objective clinical findings for 2 attacks is most secure. Reasonable historical evidence for 1 past attack, in the absence of documented objective neurological findings, can include historical events with symptoms and evolution characteristics for a prior inflammatory demyelinating event; at least 1 attack, however, must be supported by objective findings.

cNo additional tests are required. However, it is desirable that any diagnosis of MS be made with access to imaging based on these Criteria. If imaging or other tests (for instance, CSF) are undertaken and are negative, extreme caution needs to be taken before making a diagnosis of MS, and alternative diagnoses must be considered. There must be no better explanation for the clinical presentation, and objective evidence must be present to support a diagnosis of MS.

dGadolinium-enhancing lesions are not required; symptomatic lesions are excluded from consideration in subjects with brainstem or spinal cord syndromes.

MS = multiple sclerosis; CNS = central nervous system; MRI = magnetic resonance imaging; DIS = dissemination in space; DIT = dissemination in time; PPMS = primary progressive multiple sclerosis; CSF = cerebrospinal fluid; IgG = immunoglobulin G. 

2010 McDonald MRI Criteria for Demonstration of DIS:
DIS can be demonstrated by one or more T2 lesiona in at least two of four areas of the CNS:

  1. Periventricular
  2. Juxtacortical
  3. Infratentorial
  4. Spinal cordb

Based on Swanton et al 2006, 2007.
aGadolinium enhancement of lesions is not required for DIS.
bIf a subject has a brainstem or spinal cord syndrome, the symptomatic lesions are excluded from the Criteria and do not contribute to lesion count.
MRI = magnetic resonance imaging; DIS = lesion dissemination in space; CNS = central nervous system

2010 McDonald MRI Criteria for Demonstration of DIT:
DIT can be demonstrated by:

  1. A new T2 and/or gadolinium-enhancing lesion(s) on follow-up MRI, with reference to a baseline scan, irrespective of the timing of the baseline MRI
  2. Simultaneous presence of asymptomatic gadolinium-enhancing and nonenhancing lesions at any time

Based on Montalban et al 2010.

MRI = magnetic resonance imaging; DIT = lesion dissemination in time.

2010 McDonald Criteria for Diagnosis of Multiple Sclerosis in Disease with Progression from Onset:

  1. One year of disease progression (retrospectively or prospectively determined)
  2. Plus two of the three following criteriaa:
    1. Evidence for DIS in the brain based on one or more T2b lesions in at least one area characteristic for MS (periventricular, juxtacortical, or infratentorial)
    2. Evidence for DIS in the spinal cord based on two or more T2b lesions in the cord
    3. Positive CSF (isoelectric focusing evidence of oligoclonal bands and/or elevated IgG index)

aIf a subject has a brainstem or spinal cord syndrome, all symptomatic lesions are excluded from the Criteria.
bGadolinium enhancement of lesions is not required.
MS = multiple sclerosis; PPMS = primary progressive MS; DIS = lesion dissemination in space; CSF = cerebrospinal fluid; IgG = immunoglobulin G.

Definitions

Attacks: The appearance of new symptoms or the aggravation of old ones, lasting at least twenty-four hours (synonymous with exacerbation, relapse, flare-up, or worsening); usually associated with inflammation and demyelination in the brain or spinal cord.

Clinical lesion: An area of inflamed or demyelinated central nervous system tissue; synonymous with plaque

Clinically isolated syndrome (CIS): A single demyelinating episode with consistent MRI findings (indicating inflammation/demyelination in one or more sites in the CNS). Individuals with this syndrome are at high risk for developing clinically definite MS.

Primary progressive MS (PPMS): A clinical course of MS characterized by progression of disability from onset without superimposed relapses.

Progressive relapsing MS (PRMS): A primary progressive clinical course of MS characterized by clear, acute relapses, with or without full recovery from those relapses.

Relapsing-remitting MS (RRMS): A clinical course of MS characterized by clearly defined, acute relapses with full or partial recovery; no disease progression or worsening of disability develops between relapses.

Secondary progressive MS (SPMS): A clinical course of MS demonstrating sustained progression of physical disability occurring separately from relapses in individuals who previously had RRMS.

References

Peer Reviewed Publications:

  1. Anderson O, Elovaara I, Farkkila M, et al. Multicentre, randomized, double blind, placebo controlled, phase III study of weekly, low dose, subcutaneous interferon beta-1a in secondary progressive multiple sclerosis. J Neurol Neurosurg Psychiatry. 2004; 75:706-710.
  2. Barbero P, Verdun E, Bergui M, et al. High-dose frequently administered interferon beta therapy for relapsing-remitting multiple sclerosis must be maintained over the long term: the interferon beta dose-reduction study. J Neurol Sci. 2004; 222(1-2):13-19.
  3. Barkhof F, Polman CH, Radue EW, et al. Magnetic resonance imaging effects of interferon beta-1b in the BENEFIT study: integrated 2-year results. Arch Neurol. 2007;64(9):1292-1298.
  4. Bertolotto A, Sala A, Malucchi S, et al. Biological activity of interferon betas in patients with multiple sclerosis is affected by treatment regimen and neutralizing antibodies. J Neurol Neurosurg Psychiatry. 2004; 75(9):1294-1299.
  5. Clanet M, Kappos L, Radue EW, et al. Results of the European interferon beta-1a (Avonex) dose-comparison study. J Neurol. 2001; 248(suppl 2):II/63.
  6. Comi G, Filippi M, Barkhof F, et al. Effect of early interferon treatment on conversion to definite multiple sclerosis: a randomized study. Lancet. 2001; 357(9268):1576-1582.
  7. Comi G, Filippi M, Wolinsky JS. European/Canadian Glatiramer Acetate Study Group. European/ Canadian multicenter, double-blind, randomized, placebo-controlled study of the effects of glatiramer acetate on magnetic resonance imaging – measures disease activity and burden in patients with relapsing multiple sclerosis. Ann Neurol. 2001; 49(3):290-297.
  8. Coyle P. Results of comparative efficacy trial using two formulations of interferon beta-1a in RRMS. J Neurol Sci. 2001; 187(suppl 1):S436.
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  10. Edgar CM, Brunet DG, Fenton P, et al. Lipoatrophy in patients with multiple sclerosis on glatiramer acetate. Can J Neurol Sci. 2004; 31(1):58-63.
  11. Ford C, Goodman AD, Johnson K, et al. Continuous long-term immunomodulatory therapy in relapsing multiple sclerosis: results from the 15-year analysis of the US prospective open-label study of glatiramer acetate. Mult Scler. 2010; 16(3):342-350.
  12. Freedman MS, Hughes B, Mikol DD, et al. Efficacy of disease-modifying therapies in relapsing remitting multiple sclerosis: a systematic comparison. Eur Neurol. 2008; 60(1):1-11.
  13. Hartung HP, Gonsette R, Konig N, et al. Mitoxantrone in progressive multiple sclerosis: a placebo-controlled, double-blind, randomized multicentre trial. Lancet. 2002; 360(9350):2018-2025.
  14. Jacobs LD, Beck RW, Simon JH, et al. CHAMPS Study Group. Intramuscular interferon beta-1a therapy initiated during a first demyelinating event in multiple sclerosis. NEJM. 2000; 343(13):898-904.
  15. Johnson KP, Brooks BR, Ford CC, et al. Sustained clinical benefits of glatiramer acetate in relapsing multiple sclerosis patients observed for six years. Mult Scler. 2000; 6(4):255-266.
  16. Kappos L, Polman CH, Freedman MS, et al. Treatment with interferon beta-1b delays conversion to clinically definite and McDonald MS in patients with clinically isolated syndromes. Neurology. 2006; 67(7):1242-1249.
  17. Khan OA, Tselis AC, Kamholz JA, et al. A prospective, open-label treatment trial to compare the effect of IFN beta-1a (Avonex), IFN beta-1 (Betaseron), and glatiramer acetate (Copaxone) on the relapse rate in relapsing-remitting multiple sclerosis. Eur J Neurol. 2001; 8(2):141-148.
  18. Kinkel RP, Kollman C, O'Connor P, Murray TJ, et al.; CHAMPIONS Study Group. IM interferon beta-1a delays definite multiple sclerosis 5 years after a first demyelinating event. Neurology. 2006; 66(5):678-684.
  19. Li DK, Zhao GJ, Paty DW, et al. Randomized controlled trial of interferon-beta-1a in secondary progressive MS: MRI results. Neurology. 2001; 56(11):1505-1513.
  20. Metz LM, Patten SB, Archibald CJ, et al. The effect of immunomodulatory treatment on multiple sclerosis fatigue. J Neurol Neurosurg Psychiatry. 2004; 75(7):1045-1047.
  21. Mikol DD, Barkhof F, Chang P, et al.; REGARD study group. Comparison of subcutaneous interferon beta-1a with glatiramer acetate in patients with relapsing multiple sclerosis (the REbif vs Glatiramer Acetate in Relapsing MS Disease [REGARD] study): a multicentre, randomised, parallel, open-label trial. Lancet Neurol. 2008; 7(10):903-914.
  22. Miller A, Spada V, Beerkircher D, Kreitman RR. Long-term (up to 22 years), open-label, compassionate-use study of glatiramer acetate in relapsing-remitting multiple sclerosis. Mult Scler. 2008; 14(4):494-499.
  23. Montalban X, Tintoré M, Swanton J, et al. MRI criteria for MS in patients with clinically isolated syndromes. Neurology. 2010; 74(5):427-434.
  24. Pachner AR. Anti-IFNβ antibodies in INFβ-treated MS patients. Neurology. 2003; 61(Suppl 5):S1-S5.
  25. Polman CH, Reingold SC, Banwell B, et al. Diagnostic criteria for multiple sclerosis: 2010 revisions to the McDonald criteria. Ann Neurol. 2011; 69(2):292-302.
  26. Polman C, Reingold, S, Edan G, et al. Diagnostic criteria for multiple sclerosis: 2005 revisions to the "McDonald Criteria." Ann Neurol. 2005; 58(6):840-846.
  27. PRISMS Study Group and the University of British Columbia MS/MRI Analysis Group. PRISMS-4: long-term efficacy of interferon beta-1a in relapsing MS. Neurology. 2001; 56(12):1628-1636.
  28. Reder AT, Ebers GC, Traboulsee A, et al; Investigators of the 16-Year Long-Term Follow-Up Study. Cross-sectional study assessing long-term safety of interferon-beta-1b for relapsing-remitting MS. Neurology. 2010; 74(23):1877-1885.
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  30. SPECTRIMS Study Group. Randomized controlled trial of interferon-beta-1a in secondary progressive MS: clinical results. Neurology. 2001; 56(11):1496-1504.
  31. Swanton JK, Fernando K, Dalton CM, et al. Modification of MRI criteria for multiple sclerosis in patients with clinically isolated syndromes. J Neurol Neurosurg Psychiatry. 2006; 77(7):830-833.
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  34. Wolinsky JS, Narayana PA, Johnson KP, et al. United States open-label glatiramer acetate extension trial for relapsing multiple sclerosis: MRI and clinical correlates. Multiple Sclerosis Study Group and the MRI Analysis Center. Mult Scler. 2001; 7(1):33-41.
  35. Wolinsky JS, Narayana PA, O'Connor P, et al. Glatiramer acetate in primary progressive multiple sclerosis: results of a multinational, multicenter, double-blind, placebo-controlled trial. Ann Neurol. 2007; 61(1):14-24.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Hospital Formulary Service® (AHFS). AHFS Drug Information 2011®. Interferon Beta and Glatiramer Acetate. Bethesda, MD: American Society of Health-System Pharmacists®, 2011.
  2. Avonex® [Product Information], Cambridge, MA. Biogen Idec, Inc.; October, 2008. Available at:  http://www.avonex.com/msavProject/avonex.portal/_baseurl/threeColLayout/SCSRepository/en_US/avonex/
    includes/footer/prescribe_info_med_guide.xml. Accessed on June 23, 2011.
  3. Betaseron® [Product Information], Montville, NJ. Bayer HealthCare Pharmaceuticals Inc.; May 2010. Available at: http://berlex.bayerhealthcare.com/html/products/pi/Betaseron_PI.pdf. Accessed on June 23, 2011.
  4. Copaxone® [Product Information], Kansas City, MO. TEVA Neuroscience, Inc.; February 2009. Available at: http://www.accessdata.fda.gov/drugsatfda_docs/label/2009/020622s057lbl.pdf. Accessed on June 23, 2011.
  5. Extavia® [Product Information], East Hanover, NJ. Novartis Pharmaceuticals Corp.; August 2009. Available at: http://www.pharma.us.novartis.com/product/pi/pdf/extavia.pdf. Accessed on June 23, 2011.
  6. Glatiramer Acetate. In: DrugPoints ® System [Internet database]. Greenwood Village, CO: Thomson Healthcare. Updated February 25, 2011. Available at: http://www.thomsonhc.com. Accessed on June 23, 2011.
  7. Goodin DS, Frohman EM, Garmany GP Jr., et al. Disease modifying therapies in multiple sclerosis: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology and the MS Council for Clinical Practice Guidelines. Neurology. 2002; 58(2):169-178. Available at: http://www.neurology.org/cgi/reprint/58/2/169.pdf. Accessed on June 23, 2011.
  8. Interferon Beta-1a. In: DrugPoints® System [Internet database]. Greenwood Village, CO: Thomson Healthcare. Updated April 17, 2011. Available at: http://www.thomsonhc.com. Accessed on June 23, 2011.
  9. Interferon Beta-1b. In: DrugPoints® System [Internet database]. Greenwood Village, CO: Thomson Healthcare. Updated April 17, 2011. Available at: http://www.thomsonhc.com. Accessed on June 23, 2011.
  10. National Multiple Sclerosis Society. Expert Opinion Paper. Changing Therapy in Relapsing Multiple Sclerosis: Considerations and Recommendations of a Task Force of the National Multiple Sclerosis Society. 2008. Available at: http://www.nationalmssociety.org/for-professionals/healthcare-professionals/publications/expert-opinion-papers/index.aspx. Accessed on June 23, 2011.
  11. National Multiple Sclerosis Society. Expert Opinion Paper. Disease Management Consensus Statement. 2007. Available at:  http://www.nationalmssociety.org/for-professionals/healthcare-professionals/publications/expert-opinion-papers/index.aspx. Accessed on June 23, 2011.
  12. Rebif® [Product Information], Rockland, MA EMD Serono, Inc.; September 2009. Available at: http://www.mslifelines.com/_assets/pdf/Rebif_PI.pdf. Accessed on June 23, 2011.
Web Sites for Additional Information
  1. National Multiple Sclerosis Society. About MS. Available at:  http://www.nationalmssociety.org/about-multiple-sclerosis/index.aspx. Accessed on June 23, 2011.
Index

Avonex
Beta Interferons
Betaseron
Copaxone
Extavia
Glatiramer Acetate
IFN beta-1a
IFN beta-1b
Interferon Beta Agents
Rebif

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

History
StatusDateAction
Reviewed08/18/2011Medical Policy & Technology Assessment Committee (MPTAC) review. Description, Discussion (including McDonald Criteria), Reference, and Definition sections updated.
 01/01/2011Updated Coding section with 01/01/2011 HCPCS changes; removed code J1825 deleted 12/31/2010.
Revised08/19/2010MPTAC review. Clinical indication section reformatted. Clarified glatiramer acetate not medically necessary statement by removing duplicative secondary progressive MS wording. References and discussion updated.
Revised08/27/2009MPTAC revision. Drug brand names removed from clinical indications section. Removed table of FDA approved drugs with dosing and labeling information from discussion section. Removed not medically necessary statement regarding dosages greater than approved by the U.S. Food and Drug Administration (FDA). Description, discussion, references, and index updated. Information regarding Extavia added to document contents.
Revised05/21/2009MPTAC revision. Clinical indications for glatiramer acetate updated to include patients who have experienced a first clinical episode and have MRI features consistent with multiple sclerosis. Deletion of section of not medically necessary statement for glatiramer acetate referring to those with an initial demyelinating event. Place of service section deleted. Discussion and references updated.
Reviewed02/26/2009MPTAC review. Discussion and references updated. Moved "Summary of the FDA Approved Pharmaceutical Agents for the Treatment of MS" and the "International Panel Criteria" charts to the discussion/general information section of the document. Title updated.
Reviewed08/28/2008MPTAC review. Description, discussion and references updated.
 04/01/2008References updated to reflect change from USP DI® to new DrugPoints® compendia.
Reviewed08/23/2007MPTAC review. Title revised. Clinical indications clarified. Definitions and references updated.
Revised09/14/2006MPTAC revision. Update of guideline to include concomitant usage of beta interferons and glatiramer acetate or natalizumab is considered not medically necessary.
Revised06/08/2006MPTAC revision. Update of McDonald diagnostic criteria. Coding and references updated. No change to guideline position. 
New07/14/2005MPTAC initial guideline development.