BlueCross BlueShield of Tennessee Medical Policy Manual

Bevacizumab for the Treatment of Neoplastic Disease

NDC CODE(S)

50242-0060-XX Avastin 100 MG/4ML SOLN (GENENTECH)

 

50242-0061-XX Avastin 400 MG/16ML SOLN (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.

POLICY

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

MEDICAL APPROPRIATENESS

INITIAL APPROVAL

Genomic Aberration Targeted Therapies (not all inclusive)

  • Sensitizing EGFR mutation-positive tumors

    • Erlotinib

    • Afatinib

    • Gefitinib

    • Osimertinib

  • ALK rearrangement-positive tumors

    • Crizotinib

    • Ceritinib

    • Brigatinib

    • Alectinib

  • ROS1 rearrangement-positive tumors

    • Crizotinib

  • BRAF V600E-mutation positive tumors

    • Dabrafenib/Trametinib

  • PD-L1 expression-positive tumors (>50%)

    • Pembrolizumab

RENEWAL CRITERIA

INDICATION(S) DOSAGE & ADMINISTRATION
Colorectal Cancer 5 to 10 mg/kg every 2 weeks or 7.5 mg/kg every 3 weeks
NSCLC & Cervical Cancer 15 mg/kg every 3 weeks until disease progression or unacceptable toxicity.
Glioblastoma & Renal Cell Carcinoma 10 mg/kg every 2 weeks until disease progression or unacceptable toxicity.
Malignant Pleural Mesothelioma 15 mg/kg every 3 weeks in combination with chemotherapy for up to 6 cycles followed by single agent use, at the same dose/frequency, until disease progression or unacceptable toxicity.
Ovarian Cancer

Platinum-sensitive:

15 mg/kg every 3 weeks for up to 8 cycles when used with paclitaxel or up to 10 cycles when used with gemcitabine; followed by single-agent bevacizumab 15 mg/kg IV every 3 weeks until disease progression or unacceptable toxicity

Platinum-resistant:

10 mg/kg every 2 weeks or 15 mg/kg every 3 weeks until disease progression or unacceptable toxicity

All Other Oncology Indications

5-10 mg/kg every 2 weeks OR 7.5-15 mg/kg every 3 weeks

LENGTH OF AUTHORIZATION

Coverage will be provided for six months and may be renewed

Click here to view DOSAGE LIMITS

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 or prevention of other conditions or diseases.

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.

Lexi-Comp Online. (2018). AHFS DI. Bevacizumab. Retrieved February 7, 2018 from Lexi-Comp Online with AHFS.

MICROMEDEX Healthcare Series. Drugdex Drug Evaluations. (2018, February). Bevacizumab. Retrieved February 7, 2018 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. (2018). NCCN Drugs & Biologics Compendium®. Bevacizumab. Retrieved February 7, 2018 from the National Comprehensive Cancer Network.

U. S. Food and Drug Administration. (2017, December). Center for Drug Evaluation and Research. Avastin® (bevacizumab) solution for intravenous infusion. Retrieved February 7, 2018 from https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/125085s319lbl.pdf.

ORIGINAL EFFECTIVE DATE:  2/1/2005

MOST RECENT REVIEW DATE:  5/8/2018

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 for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

This document has been classified as public information.

 

 

 

DOSAGE LIMITS

Maximum billable units per dose and over time by indication as a Medical Benefit

DIAGNOSIS

BILLABLE UNIT

MAXIMUM UNITS

Oncology indications

1 billable unit = 10 mg

170 billable units per 21 days

120 billable units per 14 days