Medical Policy Updates

Notification of Policy Revisions Effective January 1, 2021 Posted October 1, 2020

Medical Policy Revision
Belantamab mafodotin-blmf (BlenrepTM) "Notification" New policy developed. Blenrep is considered medically necessary for the treatment of adult patients with multiple myeloma when specified medical criteria and guidelines are met. Added HCPCS codes C9399, J3490, J3590, J9999, S0353, and S0354 to Billing/Coding section. References added. Medical Director review 9/2020. Policy notification given 10/1/2020 for effective date 1/1/2021.
Canakinumab (Ilaris®) "Notification" New policy developed. Ilaris is considered medically necessary for the treatment of patients with autoinflammatory periodic fever syndromes (CAPS, FCAS, MWS, TRAPS, HIDS, MKD, and FMF) and active Still's disease (AOSD and SJIA) when specified medical criteria and guidelines are met. Added HCPCS code J0638 to Billing/Coding section. References added. Medical Director review 9/2020. Policy notification given 10/1/2020 for effective date 1/1/2021.
Immunoglobulin Therapy "Notification" Added HCPCS codes C9399, J3490, and J3590 to Billing/Coding section for Cutaquig subcutaneous immunoglobulin therapy effective 1/1/2021. Policy notification given 10/1/2020 for effective date 1/1/2021.
Lurbinectedin (ZepzelcaTM) "Notification" New policy developed. Zepzelca is considered medically necessary for the treatment of adult patients with small cell lung cancer (SCLC) when specified medical criteria and guidelines are met. Added HCPCS codes C9399, J3490, J3590, J9999, S0353, and S0354 to Billing/Coding section. References added. Medical Director review 9/2020. Policy notification given 10/1/2020 for effective date 1/1/2021.
Pertuzumab, Trastuzumab, and Hyaluronidase-zzxf (PhesgoTM) "Notification" New policy developed. Phesgo is considered medically necessary for the treatment of HER2-positive breast cancer when specified medical criteria and guidelines are met. Added HCPCS codes C9399, J3490, J3590, J9999, S0353, and S0354 to Billing/Coding section. References added. Medical Director review 9/2020. Policy notification given 10/1/2020 for effective date 1/1/2021.
Tafasitamab-cxix (Monjuvi®) "Notification" New policy developed. Monjuvi is considered medically necessary for the treatment of adult patients with diffuse large B-cell lymphoma (DLBCL) when specified medical criteria and guidelines are met. Added HCPCS codes C9399, J3490, J3590, J9999, S0353, and S0354 to Billing/Coding section. References added. Medical Director review 9/2020. Policy notification given 10/1/2020 for effective date 1/1/2021
White Blood Cell Growth Factors "Notification" Updated "Description", "When Covered", and "When Not Covered" sections to reflect addition of Nyvepria (pegfilgrastim-apgf), a biosimilar to Neulasta (pegfilgrastim), with same indications and coverage criteria as Udenyca, Fulphila, and Ziextenzo, and with HCPCS codes C9399, J3490, J3590 and J9999 in Billing/Coding Section. Reference added. Policy notification given 10/1/2020 for effective date 1/1/2021.