PERJETA (pertuzumab) FOR TREATMENT OF MALIGNANCIES
|
|
- Percival Grant
- 6 years ago
- Views:
Transcription
1 PERJETA (pertuzumab) FOR TREATMENT OF MALIGNANCIES Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent upon benefit eligibility as outlined in the member's specific benefit plan. This Medical Coverage Guideline must be read in its entirety to determine coverage eligibility, if any. This Medical Coverage Guideline provides information related to coverage determinations only and does not imply that a service or treatment is clinically appropriate or inappropriate. The provider and the member are responsible for all decisions regarding the appropriateness of care. Providers should provide BCBSAZ complete medical rationale when requesting any exceptions to these guidelines. The section identified as Description defines or describes a service, procedure, medical device or drug and is in no way intended as a statement of medical necessity and/or coverage. The section identified as Criteria defines criteria to determine whether a service, procedure, medical device or drug is considered medically necessary or experimental or investigational. State or federal mandates, e.g., FEP program, may dictate that any drug, device or biological product approved by the U.S. Food and Drug Administration (FDA) may not be considered experimental or investigational and thus the drug, device or biological product may be assessed only on the basis of medical necessity. Medical Coverage Guidelines are subject to change as new information becomes available. For purposes of this Medical Coverage Guideline, the terms "experimental" and "investigational" are considered to be interchangeable. BLUE CROSS, BLUE SHIELD and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. All other trademarks and service marks contained in this guideline are the property of their respective owners, which are not affiliated with BCBSAZ. O915.6.docx Page 1 of 9
2 Description: Perjeta (pertuzumab) is a monoclonal antibody that is a human epidermal growth factor receptor 2 (HER2) antagonist. The combination of two HER2-active agents targeting different subdomains of HER2 (pertuzumab targets subdomain II and trastuzumab targets subdomain IV) may result in a more comprehensive blockade of HER2 and its pathways, and thus may lead to greater treatment effect. Perjeta (pertuzumab) is FDA approval for treatment of HER2-positive, metastatic breast cancer and for the treatment of early stage HER2-positive breast cancer as neoadjuvant treatment or as adjuvant treatment. Criteria: Off-label use of a prescription drug for the treatment of cancer may be eligible for coverage. See BCBSAZ Medical Coverage Guideline #O603, Prescription Medications for the Treatment of Cancer. See Resources section for FDA-approved dosage. Perjeta (pertuzumab) for the treatment of HER2-positive breast cancer is considered medically necessary with documentation of ALL of the following: 1. ONE of the following: Metastatic breast cancer (MBC) in an individual who has not received prior anti-her2 therapy or chemotherapy for metastatic disease, used in combination with trastuzumab and docetaxel Early breast cancer, in combination with trastuzumab and chemotherapy, as ONE of the following: a. Neoadjuvant treatment of cancer that is locally advanced, inflammatory or early stage (either greater than 2 cm in diameter or node positive) as part of a complete treatment regimen b. Adjuvant treatment of cancer at high risk for recurrence 2. Absence of hypersensitivity to pertuzumab or to any pertuzumab excipients 3. Cardiac function evaluation (echocardiogram or MUGA scan) prior to initiation of therapy and close monitoring during therapy 4. Individual of child bearing potential is on effective contraception prior to initiation of therapy and up to 7 months following the last dose 5. Verification of pregnancy status prior to initiation of therapy O915.6.docx Page 2 of 9
3 Criteria: (cont.) Continuation of Perjeta (pertuzumab) is considered medically necessary with documentation of ALL of the following: 1. NO unacceptable or unmanageable toxicity from Perjeta (pertuzumab) 2. NO disease recurrence Perjeta (pertuzumab) for all other indications not previously listed or if above criteria not met is considered experimental or investigational based upon: 1. Insufficient scientific evidence to permit conclusions concerning the effect on health outcomes, and 2. Insufficient evidence to support improvement of the net health outcome, and 3. Insufficient evidence to support improvement of the net health outcome as much as, or more than, established alternatives, and 4. Insufficient evidence to support improvement outside the investigational setting. These indications include, but are not limited to: Treatment with dosing or frequency outside the FDA-approved dosing and frequency HER2-positive gastric, colorectal, non-small cell lung and ovarian cancers HER2-positive cancers of the gastro-esophageal junction HER2-negative cancers Resources: Literature reviewed 04/09/18. We do not include marketing materials, poster boards and nonpublished literature in our review. The BCBS Association Medical Policy Reference Manual (MPRM) policy is included in our guideline review. References cited in the MPRM policy are not duplicated on this guideline BCBS Association Medical Policy Reference Manual. Pertuzumab for Treatment of Malignancies. Re-issue date 10/12/2017, Issue date 12/13/2012. O915.6.docx Page 3 of 9
4 Resources: (cont.) Perjeta Package Insert: - FDA-approved indication and dosage: Indication Metastatic Breast Cancer (MBC) Recommended Dose MBC: For intravenous infusion only. Do not administer as an intravenous push or bolus. Administer Perjeta, trastuzumab and docetaxel by intravenous infusion every 3 weeks. The initial Perjeta dose is 840 mg administered as a 60-minute intravenous infusion, followed every 3 weeks thereafter by 420 mg administered as a 30 to 60 minute intravenous infusion. Dose reductions of Perjeta are not recommended. When administered with Perjeta, the recommended initial dose of trastuzumab is 8 mg/kg administered as a 90-minute intravenous infusion, followed every 3 weeks by a dose of 6 mg/kg administered as an intravenous infusion over 30 to 90 minutes. Perjeta should be discontinued if trastuzumab treatment is discontinued. When administered with Perjeta, the initial dose of docetaxel is 75mg/m 2 administered as an intravenous infusion. The dose may be escalated to 100mg/m 2 administered every 3 weeks if the initial dose is well tolerated. Perjeta, trastuzumab, and taxane (docetaxel) should be administered sequentially. Perjeta and trastuzumab can be given in any order. Taxane (docetaxel) should be administered after Perjeta and trastuzumab. An observation period of 30 to 60 minutes is recommended after each Perjeta infusion and before commencement of any subsequent infusion of trastuzumab or taxane (docetaxel). O915.6.docx Page 4 of 9
5 Resources: (cont.) Perjeta Package Insert: (cont.) - FDA-approved indication and dosage: (cont.) Indication Neoadjuvant Treatment of Early Breast Cancer Recommended Dose Neoadjuvant: Perjeta should be administered every 3 weeks for 3 to 6 cycles as part of one of the following treatment regimens for early breast cancer: 1. Four preoperative cycles of Perjeta in combination with trastuzumab and docetaxel followed by 3 postoperative cycles of fluorouracil, epirubicin, and cyclophosphamide (FEC) as given in NeoSphere Study 2. Three or four preoperative cycles of FEC alone followed by 3 or 4 preoperative cycles of Perjeta in combination with docetaxel and trastuzumab as given in TRYPHARNA and BERENICE Studies 3. Six preoperative cycles of Perjeta in combination with docetaxel, carboplatin, and trastuzumab (TCH) (escalation of docetaxel above 75mg/m2 is not recommended) as given in TRYPHARNA Study 4. Four preoperative cycles of dose-dense doxorubicin and cyclophosphamide (ddac) alone followed by 4 preoperative cycles of Perjeta in combination with paclitaxel and trastuzumab as given in BERENICE Study. Following surgery, individuals should continue to receive Perjeta and trastuzumab to complete 1 year of treatment (up to 18 cycles) The initial Perjeta dose is 840 mg administered as a 60-minute intravenous infusion, followed every 3 weeks thereafter by 420 mg administered as a 30 to 60 minute intravenous infusion. Dose reductions of Perjeta are not recommended. When administered with Perjeta, the recommended initial dose of trastuzumab is 8 mg/kg administered as a 90-minute intravenous infusion, followed every 3 weeks by a dose of 6 mg/kg administered as an intravenous infusion over 30 to 90 minutes. Perjeta should be discontinued if trastuzumab treatment is discontinued. When administered with Perjeta, the initial dose of docetaxel is 75mg/m 2 administered as an intravenous infusion. The dose may be escalated to 100mg/m 2 administered every 3 weeks if the initial dose is well tolerated and as per protocol used. O915.6.docx Page 5 of 9
6 Resources: (cont.) Perjeta Package Insert: (cont.) - FDA-approved indication and dosage: (cont.) Indication Neoadjuvant Treatment of Early Breast Cancer (cont.) Recommended Dose Perjeta, trastuzumab, and taxane (docetaxel, paclitaxel) should be administered sequentially. Perjeta and trastuzumab can be given in any order. Taxane (docetaxel, paclitaxel) should be administered after Perjeta and trastuzumab. An observation period of 30 to 60 minutes is recommended after each Perjeta infusion and before commencement of any subsequent infusion of trastuzumab or taxane (docetaxel, paclitaxel). In individuals receiving an anthracycline-based regimen, Perjeta and trastuzumab should be administered following completion of the anthracycline. Adjuvant Treatment of Early Breast Cancer at High Risk of Recurrence PERJETA should be administered in combination with trastuzumab every 3 weeks for a total of 1 year (up to 18 cycles) or until disease recurrence or unmanageable toxicity, whichever occurs first, as part of a complete regimen for early breast cancer, including standard anthracycline- anthracycline and/or taxane-based chemotherapy as given in APHINITY Study. PERJETA and trastuzumab should start on Day 1 of the first taxane-containing cycle. The initial Perjeta dose is 840 mg administered as a 60-minute intravenous infusion, followed every 3 weeks thereafter by 420 mg administered as a 30 to 60 minute intravenous infusion. Dose reductions of Perjeta are not recommended. When administered with Perjeta, the recommended initial dose of trastuzumab is 8 mg/kg administered as a 90-minute intravenous infusion, followed every 3 weeks by a dose of 6 mg/kg administered as an intravenous infusion over 30 to 90 minutes. Perjeta should be discontinued if trastuzumab treatment is discontinued. Perjeta, trastuzumab, and taxane should be administered sequentially. Perjeta and trastuzumab can be given in any order. Taxane should be administered after Perjeta and trastuzumab. An observation period of 30 to 60 minutes is recommended after each Perjeta infusion and before commencement of any subsequent infusion of trastuzumab or taxane. In individuals receiving an anthracycline-based regimen, Perjeta and trastuzumab should be administered following completion of the anthracycline. O915.6.docx Page 6 of 9
7 Resources: (cont.) Initial Approval Duration: For MBC & EBC: 6 months Renewal Approval Duration: For MBC: 12 months For EBC: 6 month (for up to 18 cycles) O915.6.docx Page 7 of 9
8 Non-Discrimination Statement: Blue Cross Blue Shield of Arizona (BCBSAZ) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. BCBSAZ provides appropriate free aids and services, such as qualified interpreters and written information in other formats, to people with disabilities to communicate effectively with us. BCBSAZ also provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, call (602) for Spanish and (877) for all other languages and other aids and services. If you believe that BCBSAZ has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with: BCBSAZ s Civil Rights Coordinator, Attn: Civil Rights Coordinator, Blue Cross Blue Shield of Arizona, P.O. Box 13466, Phoenix, AZ , (602) , TTY/TDD (602) , crc@azblue.com. You can file a grievance in person or by mail or . If you need help filing a grievance BCBSAZ s Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, , (TDD). Complaint forms are available at Multi-Language Interpreter Services: O915.6.docx Page 8 of 9
9 Multi-Language Interpreter Services: (cont.) O915.6.docx Page 9 of 9
LARTRUVO (olaratumab)
LARTRUVO (olaratumab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationMEDICAL COVERAGE GUIDELINES ORIGINAL EFFECTIVE DATE: 10/04/17 SECTION: DRUGS LAST REVIEW DATE: LAST CRITERIA REVISION DATE: ARCHIVE DATE:
BAVENCIO (avelumab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationENDOBRONCHIAL ULTRASOUND FOR DIAGNOSIS AND STAGING OF LUNG CANCER
CANCER Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent
More informationGENETIC TESTING FOR TAMOXIFEN TREATMENT
GENETIC TESTING FOR TAMOXIFEN TREATMENT Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical
More informationPANCREATIC ISLET TRANSPLANT
PANCREATIC ISLET TRANSPLANT Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationGENETIC TESTING FOR PREDICTING RISK OF NONFAMILIAL BREAST CANCER
Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent upon
More informationINTRAPERITONEAL CHEMOTHERAPY, CYTOREDUCTION
INTRAPERITONEAL CHEMOTHERAPY, CYTOREDUCTION Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures,
More informationGENETIC TESTING FOR KRAS, NRAS AND BRAF VARIANT ANALYSIS IN METASTATIC COLORECTAL CANCER
METASTATIC COLORECTAL CANCER Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationHEMATOPOIETIC CELL TRANSPLANTATION FOR EPITHELIAL OVARIAN CARCINOMA
CARCINOMA Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent
More informationIMMUNE CELL FUNCTION ASSAY
IMMUNE CELL FUNCTION ASSAY Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and
More informationRADIOFREQUENCY ABLATION OF PRIMARY OR METASTATIC LIVER TUMORS
Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent upon
More informationMYLOTARG (gemtuzumab ozogamicin)
MYLOTARG (gemtuzumab ozogamicin) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationMOLECULAR TESTING IN THE MANAGEMENT OF PULMONARY NODULES
MOLECULAR TESTING IN THE MANAGEMENT OF PULMONARY NODULES Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services,
More informationALPHA1-PROTEINASE INHIBITORS
ALPHA1-PROTEINASE INHIBITORS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationDRUG TESTING IN PAIN MANAGEMENT AND SUBSTANCE USE DISORDER(S) TREATMENT
TREATMENT Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent
More informationSTELARA (ustekinumab)
STELARA (ustekinumab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationENTYVIO (vedolizumab)
ENTYVIO (vedolizumab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationVYXEOS (daunorubicin and cytarabine)
VYXEOS (daunorubicin and cytarabine) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical
More informationNon-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document.
HYDROXYPROGESTERONE THERAPY Makena (hydroxyprogesterone caproate injection) Hydroxyprogesterone caproate compound Hydroxyprogesterone caproate injection with benzyl benzoate and the preservative benzyl
More informationPROTEOMIC TESTING FOR SYSTEMIC THERAPY IN NON-SMALL-CELL LUNG CANCER
CANCER Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent
More informationMULTIMARKER SERUM TESTING RELATED TO OVARIAN CANCER
MULTIMARKER SERUM TESTING RELATED TO OVARIAN CANCER Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures,
More informationRADIOFREQUENCY ABLATION OF MISCELLANEOUS SOLID TUMORS EXCLUDING LIVER TUMORS
EXCLUDING LIVER TUMORS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationBLINCYTO (blinatumomab)
BLINCYTO (blinatumomab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and
More informationNOVEL BIOMARKERS IN RISK ASSESSMENT AND MANAGEMENT OF CARDIOVASCULAR DISEASE
CARDIOVASCULAR DISEASE Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationRELISTOR (methylnaltrexone bromide) INJECTION FOR SUBCUTANEOUS USE
RELISTOR (methylnaltrexone bromide) INJECTION FOR SUBCUTANEOUS USE Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for
More informationINTRAVITREAL IMPLANTS
INTRAVITREAL IMPLANTS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationSOMATULINE DEPOT (lanreotide acetate)
SOMATULINE DEPOT (lanreotide acetate) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical
More informationCONTINUOUS OR INTERMITTENT GLUCOSE MONITORING IN INTERSTITIAL FLUID
FLUID Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent
More informationHEMATOPOIETIC CELL TRANSPLANTATION FOR PRIMARY AMYLOIDOSIS
Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent upon
More informationPARSABIV (etelcalcetide)
PARSABIV (etelcalcetide) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and
More informationINTRACAVITARY BALLOON BRACHYTHERAPY FOR MALIGNANT AND METASTATIC BRAIN TUMORS
METASTATIC BRAIN TUMORS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and
More informationORAL IMPLANT PROCEDURES
ORAL IMPLANT PROCEDURES Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and
More informationAPOKYN (apomorphine hydrochloride)
APOKYN (apomorphine hydrochloride) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationFECAL ANALYSIS IN THE DIAGNOSIS OF INTESTINAL DYSBIOSIS
FECAL ANALYSIS IN THE DIAGNOSIS OF INTESTINAL DYSBIOSIS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services,
More informationGATTEX (teduglutide [rdna origin])
GATTEX (teduglutide [rdna origin]) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationCIMZIA (certolizumab pegol)
CIMZIA (certolizumab pegol) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationTREATMENTS FOR GAUCHER DISEASE
TREATMENTS FOR GAUCHER DISEASE Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationGENETIC TESTING FOR HEREDITARY HEARING LOSS
GENETIC TESTING FOR HEREDITARY HEARING LOSS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures,
More informationNUTRIENT OR NUTRITIONAL PANEL TESTING
NUTRIENT OR NUTRITIONAL PANEL TESTING Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical
More informationNon-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document.
NUCALA (mepolizumab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationNEGATIVE PRESSURE WOUND THERAPY
NEGATIVE PRESSURE WOUND THERAPY Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationCARDIOVASCULAR RISK PANELS
CARDIOVASCULAR RISK PANELS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and
More informationTYMLOS (abaloparatide)
TYMLOS (abaloparatide) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationNon-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document.
ERYTHROPOIESIS-STIMULATING AGENTS (ESAs) Epoetin alfa (Epogen, Procrit ) Darbepoetin alfa (Aranesp ) Methoxy polyethylene glycol (PEG) epoetin-beta (Mircera ) Non-Discrimination Statement and Multi-Language
More informationTYSABRI FOR CROHN S DISEASE
TYSABRI FOR CROHN S DISEASE Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationGENETIC TESTING FOR MARFAN SYNDROME, THORACIC AORTIC ANEURYSMS AND DISSECTIONS AND RELATED DISORDERS
AND DISSECTIONS AND RELATED DISORDERS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical
More informationGENETIC TESTING FOR FANCONI ANEMIA
GENETIC TESTING FOR FANCONI ANEMIA Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationBONIVA (ibandronate sodium)
BONIVA (ibandronate sodium) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationDERMATOLOGIC APPLICATIONS OF PHOTODYNAMIC THERAPY
DERMATOLOGIC APPLICATIONS OF PHOTODYNAMIC THERAPY Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures,
More informationGENETIC TESTING FOR NEUROFIBROMATOSIS
GENETIC TESTING FOR NEUROFIBROMATOSIS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical
More informationBALLOON OSTIAL DILATION FOR TREATMENT OF CHRONIC SINUSITIS
BALLOON OSTIAL DILATION FOR TREATMENT OF CHRONIC SINUSITIS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services,
More informationDEEP BRAIN STIMULATION
DEEP BRAIN STIMULATION Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationPERCUTANEOUS BALLOON KYPHOPLASTY, RADIOFREQUENCY KYPHOPLASTY, AND MECHANICAL VERTEBRAL AUGMENTATION
KYPHOPLASTY, AND MECHANICAL VERTEBRAL AUGMENTATION Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures,
More informationINTERSPINOUS FIXATION (FUSION) DEVICES
INTERSPINOUS FIXATION (FUSION) DEVICES Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical
More informationNon-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document.
MRI OF THE BREAST Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationNon-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document.
XOLAIR (omalizumab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationGENETIC TESTING FOR FLT3, NPM1 AND CEBPA VARIANTS IN CYTOGENETICALLY NORMAL ACUTE MYELOID LEUKEMIA
CYTOGENETICALLY NORMAL ACUTE MYELOID LEUKEMIA Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures,
More informationBRINEURA (cerliponase alfa)
BRINEURA (cerliponase alfa) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationTRANSMYOCARDIAL REVASCULARIZATION
TRANSMYOCARDIAL REVASCULARIZATION Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationHEMATOPOIETIC CELL TRANSPLANTATION FOR HODGKIN LYMPHOMA
HEMATOPOIETIC CELL TRANSPLANTATION FOR HODGKIN LYMPHOMA Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services,
More informationGENETIC TESTING WITH MOLECULAR PANEL TESTING OF CANCERS TO IDENTIFY TARGETED THERAPIES
IDENTIFY TARGETED THERAPIES Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationBIVENTRICULAR PACEMAKER (CARDIAC RESYNCHRONIZATION THERAPY) FOR THE TREATMENT OF HEART FAILURE
FOR THE TREATMENT OF HEART FAILURE Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationGENE EXPRESSION PROFILING AND PROTEIN BIOMARKERS FOR PROSTATE CANCER MANAGEMENT
CANCER MANAGEMENT Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationELECTROMYOGRAPHY (EMG) AND NERVE CONDUCTION STUDIES (NCS)
ELECTROMYOGRAPHY (EMG) AND NERVE CONDUCTION STUDIES (NCS) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services,
More informationOPTICAL COHERENCE TOMOGRAPHY (OCT) OF THE MIDDLE EAR
OPTICAL COHERENCE TOMOGRAPHY (OCT) OF THE MIDDLE EAR Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures,
More informationGENETIC TESTING FOR HEREDITARY BREAST AND OVARIAN CANCER SYNDROME BRCA1 BRCA2
SYNDROME BRCA1 BRCA2 Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationKYMRIAH (tisagenlecleucel)
KYMRIAH (tisagenlecleucel) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and
More informationH.P. ACTHAR GEL (repository corticotropin injection)
H.P. ACTHAR GEL (repository corticotropin injection) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures,
More informationHEMATOPOIETIC CELL TRANSPLANTATION FOR SOLID TUMORS OF CHILDHOOD
CHILDHOOD Non-Discrimination Statement Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices drugs are dependent upon
More informationAUTOLOGOUS CHONDROCYTE IMPLANTATION FOR FOCAL ARTICULAR CARTILAGE LESIONS
CARTILAGE LESIONS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationELECTRIC TUMOR TREATMENT FIELDS
ELECTRIC TUMOR TREATMENT FIELDS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationGENETIC TESTING FOR TARGETED THERAPY FOR NON-SMALL CELL LUNG CANCER (NSCLC)
CANCER (NSCLC) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are
More informationLIMB COMPRESSION DEVICES FOR VENOUS THROMBOEMBOLISM PROPHYLAXIS
PROPHYLAXIS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent
More informationINJECTABLE BULKING AGENTS FOR THE TREATMENT OF URINARY AND FECAL INCONTINENCE
FECAL INCONTINENCE Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationPERCUTANEOUS TIBIAL NERVE STIMULATION
PERCUTANEOUS TIBIAL NERVE STIMULATION Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical
More informationNASAL AIRWAY EVALUATION Acoustic Reflex Technology Acoustic Rhinometry Optical Rhinometry Rhinomanometry Sleep Sonography
NASAL AIRWAY EVALUATION Acoustic Reflex Technology Acoustic Rhinometry Optical Rhinometry Rhinomanometry Sleep Sonography Non-Discrimination Statement and Multi-Language Interpreter Services information
More informationHEMATOPOIETIC CELL TRANSPLANTATION FOR CHRONIC MYELOID LEUKEMIA
LEUKEMIA Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent
More informationDYNAMIC SPINAL VISUALIZATION
DYNAMIC SPINAL VISUALIZATION Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationACTEMRA (tocilizumab)
ACTEMRA (tocilizumab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationMEDICAL COVERAGE GUIDELINES ORIGINAL EFFECTIVE DATE: 03/07/18 SECTION: DRUGS LAST REVIEW DATE: 02/19/19 LAST CRITERIA REVISION DATE: ARCHIVE DATE:
FUZEON (enfuvirtide) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationPERCUTANEOUS TIBIAL NERVE STIMULATION
PERCUTANEOUS TIBIAL NERVE STIMULATION Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical
More informationBREAST RECONSTRUCTION/REMOVAL AND REPLACEMENT OF IMPLANTS
Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent upon
More informationMEDICAL COVERAGE GUIDELINES ORIGINAL EFFECTIVE DATE: 11/14/17 SECTION: DRUGS LAST REVIEW DATE: LAST CRITERIA REVISION DATE: ARCHIVE DATE:
RADICAVA (edaravone) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationYESCARTA (axicabtagene ciloleucel)
YESCARTA (axicabtagene ciloleucel) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationLUXTURNA (voretigene neparovec-rzyl)
LUXTURNA (voretigene neparovec-rzyl) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical
More informationINTRAOPERATIVE RADIATION THERAPY
INTRAOPERATIVE RADIATION THERAPY Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationSTRENSIQ (asfotase alfa)
STRENSIQ (asfotase alfa) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and
More informationCOSENTYX (secukinumab)
COSENTYX (secukinumab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationMEDICAL COVERAGE GUIDELINES ORIGINAL EFFECTIVE DATE: 12/19/17 SECTION: MEDICINE LAST REVIEW DATE: LAST CRITERIA REVISION DATE: ARCHIVE DATE:
MEDICAL FOODS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are
More informationALPHA-FETOPROTEIN-L3 FOR DETECTION OF HEPATOCELLULAR CANCER
Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent upon
More informationPERCUTANEOUS TRANSCATHETER CLOSURE OF PARAVALVULAR LEAK
Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent upon
More informationVESTIBULAR FUNCTION TESTING
VESTIBULAR FUNCTION TESTING Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationMEASUREMENT OF EXHALED NITRIC OXIDE AND EXHALED BREATH CONDENSATE
CONDENSATE Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent
More informationDECISIONDx BIOMARKER TESTS
DECISIONDx BIOMARKER TESTS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and
More informationNon-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document.
PEYRONIE S DISEASE TREATMENTS Extracorporeal Shock Wave Therapy (ESWT) Iontophoresis Nesbit Plication Plaque Incision with Graft Xiaflex (collagenase clostridium histolyticum) Non-Discrimination Statement
More informationRADIOFREQUENCY ABLATION OR CRYOABLATION FOR ESOPHAGEAL DISORDERS
DISORDERS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent
More informationHEMATOPOIETIC CELL TRANSPLANTATION FOR PLASMA CELL DYSCRASIAS Multiple Myeloma POEMS Syndrome
Multiple Myeloma POEMS Syndrome Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationENTYVIO (vedolizumab)
ENTYVIO (vedolizumab) Coverage for services, procedures, medical devices and drugs are dependent upon benefit eligibility as outlined in the member's specific benefit plan. This Medical Coverage Guideline
More informationMYALEPT (metreleptin)
MYALEPT (metreleptin) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationHEMATOPOIETIC CELL TRANSPLANTATION FOR GENETIC DISEASES AND ACQUIRED ANEMIAS
ACQUIRED ANEMIAS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are
More information