BlueCross BlueShield of Tennessee Medical Policy Manual

Bevacizumab for the Treatment of Neoplastic Disease

NDC CODE(S)

Avastin 100mg/4ml solution for injection: 50242-0060-xx (Genentech)

 

Avastin 400mg/16ml solution for injection: 50242-0061-xx (Genentech)

DESCRIPTION

Bevacizumab is a recombinant humanized monoclonal IgG1 antibody which binds to human vascular endothelial growth factor (VEGF).  VEGF normally interacts with receptors (Flt-1 and KDR) on the surface of endothelial cells and leads to endothelial cell proliferation and new blood vessel formation.  By binding to VEGF, bevacizumab halts interaction with these receptors, resulting in reduction of microvascular growth and inhibition of metastatic disease progression.

Note: This policy does not address the use of bevacizumab for the treatment of disorders of the eye.  Preauthorization is not needed for Avastin when used in the treatment of eye disorders.

REFER TO DECISION SUPPORT TREE

POLICY

See also: Human Epidermal Receptor Type 2 (HER 2) Testing

MEDICAL APPROPRIATENESS

INITIAL APPROVAL

RENEWAL CRITERIA

INDICATION(S) DOSAGE & ADMINISTRATION
Neoplastic disease 10mg/kg every 2 weeks OR 15mg/kg every 3 weeks for a period of 6 months

APPLICABLE TENNESSEE STATE MANDATE REQUIREMENTS

BlueCross BlueShield of Tennessee’s Medical Policy complies with Tennessee Code Annotated Section 56-7-2352 regarding coverage of off-label indications of Food and Drug Administration (FDA) approved drugs when the off-label use is recognized in one of the statutorily recognized standard reference compendia or in the published peer-reviewed medical literature.

IMPORTANT REMINDER

We develop Medical Policies to provide guidance to Members and Providers.  This Medical Policy relates only to the services or supplies described in it.  The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy.  For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed.  If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.

ADDITIONAL INFORMATION 

For appropriate chemotherapy regimens, dosage information, contraindications, precautions, warnings, and monitoring information, please refer to one of the standard reference compendia (e.g., the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) published by the National Comprehensive Cancer Network®, Drugdex Evaluations of Micromedex Solutions at Truven Health, or The American Hospital Formulary Service Drug Information).

No controlled studies were found in the published literature that validate the use of bevacizumab for the treatment of indications outside the scope of this policy for neoplastic disease.

SOURCES

Anandan, S. & Bilodeau, C. C. Acoustic neuroma. In Ferri, F. F.(Ed.), Ferri’s Clinical Advisor 2013 (1st ed. sec.1). Philadelphia, PA: Mosby, Elsevier.

BlueCross BlueShield Association. Medical Policy Reference Manual. (10:2013). Bevacizumab in advanced adenocarcinoma of the pancreas (5.01.18). Retrieved August 12, 2014 from BlueWeb.

Lexi-Comp Online. (2016, October). AHFS DI. Bevacizumab. Retrieved January 18, 2017 from Lexi-Comp Online with AHFS.

MICROMEDEX Healthcare Series. Drugdex Drug Evaluations. (2017, January). Bevacizumab. Retrieved January 18, 2017 from MICRODEX Healthcare Series.

Mink. J. W. (2011). Congenital, developmental, and neurocutaneous disorders. In Goldman, L. & Schafer, A. I. (Eds.), Goldman’s Cecil medicine (ch. 426). Philadelphia, PA: Saunders, Elsevier.

National Comprehensive Cancer Network. (2016). NCCN Drugs & Biologics Compendium™. Bevacizumab. Retrieved January 19, 2017 from the National Comprehensive Cancer Network.

U. S. Food and Drug Administration. (2016, December). Center for Drug Evaluation and Research. Avastin® (bevacizumab) solution for intravenous infusion. Retrieved January 18, 2017 from http://www.accessdata.fda.gov/scripts/cder/daf/index.cfm?event=BasicSearch.process.

ORIGINAL EFFECTIVE DATE:  2/1/2005

MOST RECENT REVIEW DATE:  4/11/2017

ID_MRx

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute

Pharmaceutical Decision Support Tree

Bevacizumab (Avastin®) for the Treatment of Neoplastic Disease

Note: This policy does not address the use of bevacizumab for the treatment of disorders of the eye. Preauthorization is not needed for Avastin when used in the treatment of eye disorders.   

  1. Is this the initial request for the agent?

If yes, go to question #2

If no, go to question #15

  1. Does the individual have a diagnosis of Breast Cancer that is recurrent or metastatic for treatment in combination with paclitaxel and diagnosed as invasive HER2-negative disease that is ANY ONE of the following?

If yes, go to question #14

If no, go to question #3

  1. Does the individual have a diagnosis of Primary Central Nervous System Cancer further diagnosed as ANY ONE of the following?

If yes, go to question #14

If no, go to question #4

  1. Does the individual have a diagnosis of Cervical Cancer that is persistent, recurrent or metastatic as first-line therapy with paclitaxel and cisplatin (Platinol®) or topotecan (Hycamtin®)?

If yes, go to question #14

If no, go to question #5

  1. Does the individual have a diagnosis of Colorectal Cancer that is ANY ONE of the following?

If yes, go to question #14

If no, go to question #6

  1. Does the individual have a diagnosis of Malignant Pleural Mesothelioma in combination with pemetrexed (Alimta®) and cisplatin (Platinol®) followed by single-agent maintenance therapy that is ANY ONE of the following?

If yes, go to question #14

If no, go to question #7

  1. Does the individual have a diagnosis of Neurofibromatosis diagnosed as type 2 (NF2) exhibiting ALL of the following?

If yes, go to question #14

If no, go to question #8

  1. Does the individual have a diagnosis of nonsquamous non-small cell lung cancer (NSCLC) that is recurrent, unresectable, locally advanced or metastatic if ANY ONE of the following?

If yes, go to question #14

If no, go to question #9

  1. Does the individual have a diagnosis of Ovarian Cancer diagnosed as epithelial ovarian, fallopian tube or primary peritoneal cancer that is persistent or recurrent and bevacizumab has not been used previously if ALL of the following?

If yes, go to question #14

If no, go to question #10

  1. Does the individual have a diagnosis of Ovarian cancer diagnosed as malignant sex cord-stromal tumors if ALL of the following?

If yes, go to question #14

If no, go to question #11

  1. Does the individual have a diagnosis of Renal Cell Carcinoma (kidney cancer) that is metastatic or relapsed and ANY ONE of the following?

If yes, go to question #14

If no, go to question #12

  1. Does the individual have a diagnosis of Soft tissue sarcoma further diagnosed as ANY ONE of the following?

If yes, go to question #14

If no, go to question #13

  1. Does the individual have a diagnosis of Uterine Neoplasms further diagnosed as endometrial carcinoma with histology of serous or clear cell adenocarcinoma or carcinosarcoma requesting single-agent therapy for disease that has progressed on prior cytotoxic chemotherapy?

If yes, go to question #14

If no, this does not meet medical necessity and/or medical appropriateness criteria

  1. Is the request for 170 billable units or less per 21 days for dosage of 10mg/kg every 2 weeks OR 15mg/kg every 3 weeks for an authorization period of six months?

If yes, this satisfies medical necessity and medical appropriateness criteria

If no, this does not meet medical necessity and/or medical appropriateness criteria

  1. Does the individual continue to meet initial approval criteria in questions 2 through 14?

If yes, go to question #16

If no, this does not meet medical necessity and/or medical appropriateness criteria

  1. Does the individual have a diagnosis of metastatic carcinoma of the colon or rectum if disease has progressed on a first-line bevacizumab-containing regimen and ANY ONE of the following?

If yes, go to question #19

If no, this does not meet medical necessity and/or medical appropriateness criteria

  1. Does the individual have a diagnosis of Malignant Pleural Mesothelioma with a request for bevacizumab as a single agent as maintenance therapy?

If yes, go to question #19

If no, go to question #18

  1. Does the individual have a diagnosis of Non-Squamous Non-Small Cell Lung Cancer with a request for bevacizumab as a single agent or with Alimta® (pemetrexed) as maintenance therapy?

If yes, go to question #19

If no, this does not meet medical necessity and/or medical appropriateness criteria

  1. Is tumor response is evident from stabilization of disease or decrease in size of tumor or tumor spread with absence of unacceptable toxicity from the agent?

If yes, this satisfies medical necessity and medical appropriateness criteria

If no, this does not meet medical necessity and/or medical appropriateness criteria

This document has been classified as public information.