BlueCross BlueShield of Tennessee Medical Policy Manual

Pembrolizumab

DESCRIPTION

Pembrolizumab is a human programmed death receptor (PD-1)-blocking humanized monoclonal antibody.  It blocks the interaction between PD-1 and its ligands, PD-L1 and PD-L2 by binding to the PD-1 receptor which is found on T-cells.  This releases PD-1 pathway-mediated inhibition of the immune response, including the anti-tumor immune response, which results in decreased tumor growth.

POLICY

• Pembrolizumab for the treatment of the following is considered medically necessary if the medical appropriateness criteria are met: (See Medical Appropriateness below.)

• • Anal cancer

  • Bone Cancer

  • Bladder Cancer/Urothelial Carcinoma

  • Breast Cancer

  • Central Nervous System Cancers

  • Cervical cancer

  • Diffuse Large B-Cell Lymphoma

  • Endometrial Carcinoma (Uterine Cancer)

  • Esophageal Cancer

  • Gastric cancer

  • Gestational Trophoblastic Neoplasia

  • Head and Neck Cancers

  • Hepatocellular Carcinoma (HCC)

  • Hodgkin Lymphoma

  • Melanoma

  • Merkel cell carcinoma

  • Mesothelioma

  • Microsatellite Instability-High (MSI-H)/ Mismatch Repair Deficient (dMMR) Cancers

  • Mycosis Fungoides/Sézary Syndrome

  • Non-small cell lung cancer (NSCLC)

  • Primary Mediastinal Large B-Cell Lymphoma (PMBCL)

  • Renal Cell Carcinoma (Kidney Cancer)

  • Small Cell Lung Cancer

  • Squamous Cell Carcinoma of the Head and Neck (SCCHN)

  • T-Cell Lymphoma/Extranodal NK, nasal type

  • Thymic carcinoma

  • Vulvar Cancer

• Pembrolizumab for the treatment of other conditions/diseases is considered investigational.

MEDICAL APPROPRIATENESS

INITIAL APPROVAL

• Pembrolizumab is considered medically appropriate if ALL of the following: 

• • Individual is 18 years of age or older unless otherwise specified

  • Individual has not received previous therapy with a programmed death (PD-1/PD-L1) -directed therapy (e.g., atezolizumab, avelumab, cemiplimab, durvalumab, nivolumab, etc.) unless otherwise specified

  • Diagnosis of ANY ONE of the following:

  • • Anal Cancer if ALL of the following:

    • • Disease is metastatic squamous cell

      • Used as a single agent in second-line or subsequent therapy

    • Bladder Cancer/Urothelial Carcinoma if ALL of the following:

    • • Used as a single agent

      • Further diagnosed as ANY ONE of the following:

      • • Bacillus Calmette-Guerin (BCG)-unresponsive, non-muscle invasive bladder cancer (NMIBC)* if ALL of the following:

        • • Diagnosis of carcinoma in situ (CIS)

          • Disease is high-risk with or without papillary tumors

          • Individual is ineligible for or has elected not to undergo cystectomy

*Defined as ANY ONE of the following:

• 1. • 1. • • Persistent disease despite adequate BCG therapy

            • Disease recurrence after an initial tumor free state following an adequate BCG course of therapy [i.e., administration of at least five of six doses of an initial induction course AND at least two of three doses of maintenance therapy or at least two of six doses of a second induction course]

            • T1 disease following a single induction course of BCG

          • Primary Carcinoma of the Urethra as ANY ONE of the following:

          • • Recurrent (excluding recurrence of stage T3-4 disease or palpable inguinal lymph nodes) or metastatic disease

            • Used as primary treatment for clinical stage T3-4, cN1-2 disease or cN1-2 palpable inguinal lymph nodes

          • Locally advanced or metastatic Urothelial Carcinoma

          • Disease recurrence post-cystectomy

          • Metastatic Upper GU Tract Tumors

          • Metastatic Urothelial Carcinoma of the Prostate

     • Used as ANY ONE of the following:

     • • First-line therapy in cisplatin-ineligible** patients if ANY ONE of the following:

       • • Individual is carboplatin-ineligible**

         • • Individual has a PD-L1 Combined Positive Score (CPS) of ≥10 as determined by an FDA-approved or CLIA-compliant test***

     • Subsequent therapy after previous platinum treatment**

• Breast Cancer if ALL of the following:

• • Disease is recurrent or stage IV (M1) that is metastatic or unresectable and has progressed following prior treatment

  • Individual has no satisfactory alternative treatment options

• Central Nervous System Cancer if ALL of the following:

• • Used as a single agent

  • Primary tumor is due to melanoma or PD-L1 positive non-small cell lung cancer (NSCLC) in individuals with ANY ONE of the following:

  • • Limited brain metastases if disease is ANY ONE of the following:

    • • Recurrent brain metastases

      • Newly diagnosed small asymptomatic brain metastases with stable disease or when reasonable systemic treatment options exist

    • Extensive brain metastases if used for stable disease or when reasonable systemic treatment options exist

• Cervical Cancer if ALL of the following:

• • Used as a single agent

  • Individual has recurrent or metastatic disease

  • Tumor expresses PD-L1 with a CPS ≥1 as determined by an FDA-approved or CLIA-compliant  test***

  • Disease progressed on or after chemotherapy

• Diffuse Large B-Cell Lymphoma diagnosed as Primary Mediastinal Large B-Cell Lymphoma (PMBCL) if ALL of the following:

• • Individual must be at least 2 years of age or older

  • Used as single agent

  • Individual  has relapsed or refractory disease

• Endometrial Carcinoma (Uterine Cancer) if ALL of the following:

• • Disease is advanced or recurrent

  • Disease has progression following prior systemic therapy

  • Individual is not a candidate for curative surgery or radiation

  • Used in combination with lenvatinib

• Esophageal Cancer if ALL of the following:

• • Used as a single agent

  • Diagnosis of recurrent, unresectable (or is not a candidate for surgery) locally-advanced, or metastatic disease

  • Tumor expresses PD-L1 (CPS ≥ 10) as determined by an FDA-approved or CLIA-compliant test***

  • Individual with HER2 positive disease must have previously failed on HER2 directed therapy

  • Disease is ANY ONE of the following:

  • • Squamous cell histology (SCC, squamous cell carcinoma) with disease progression on or after at least one prior systemic treatment

    • Adenocarcinoma if ALL of the following:

    • • Used as third-line or subsequent therapy

      • Individual with ECOG performance score ≤ 2 or Karnofsky performance score ≥ 60%

• Gastric cancer if ALL of the following:

• • Used as a single agent

  • Diagnosis of gastric or gastroesophageal junction (GEJ) adenocarcinoma

  • Disease is recurrent, unresectable (or not a surgical candidate) or metastatic

  • Tumor expresses PD-L1 (CPS ≥1) as determined by an FDA-approved or CLIA-compliant test***

  • Disease progression on or after minimum of two prior systemic treatments

• Gestational Trophoblastic Neoplasia if used as single agent therapy for ANY ONE of the following:

• • Recurrent or progressive intermediate trophoblastic tumor (placental site trophoblastic tumor or epithelioid trophoblastic tumor) following treatment with a platinum/etoposide-containing regimen

  • Methotrexate-resistant high-risk disease

• Hepatocellular Carcinoma (HCC) if ALL of the following:

• • Used as a single agent

  • Progressed on or was intolerant to sorafenib

  • Laboratory confirmed diagnosis of hepatocellular carcinoma

  • Child-Pugh Class A liver impairment ONLY (excluding Child-Pugh Class B and C)

• Hodgkin lymphoma, diagnosed as Classical Hodgkin lymphoma (cHL) if ALL of the following:

• • Used as a single agentfor ANY ONE of the following:

  • • Individual is at least 18 years old and has received two or more prior lines of therapy OR used as palliative therapy in patients more than 60 years old if ANY ONE of the following:

    • • Disease has relapsed or progressed after autologous hematopoietic stem cell transplant    HSCT) with or without brentuximab vedotin

      • Relapsed or refractory disease and is either transplant-ineligible based on comorbidity or failure of second-line chemotherapy

      • Post-allogeneic transplant

    • Individual is 2 years of age or older and has relapsed or refractory disease or relapsed after three or more prior lines of therapy

• Melanoma, Cutaneous, as a single agent used for ANY ONE of the following:

• • Metastatic or unresectable disease or stage III disease with satellite/intransit metastases used as ANY ONE of the following:

  • • First-line therapy

    • Subsequent therapy

    • Retreatment of disease as re-induction therapy in individuals who experienced disease control (i.e., complete response, partial response, or stable disease with no residual toxicity) from prior checkpoint inhibitor therapy, but subsequently have disease progression/relapse > 3 months after treatment discontinuation

  • Adjuvant treatment if individual has ANY ONE of the following:

  • • Lymph node involvement and has undergone complete resection, complete lymph node dissection (CLND), therapeutic lymph node dissection (TLND), or nodal basin ultrasound surveillance

    • Satellite/in-transit metastases or recurrence and has no evidence of disease after complete excision

    • Undergone TLND and/or complete resection of nodal recurrence

    • Undergone complete resection of distant metastatic disease

• Melanoma, Uveal, with distant metastatic disease, used as a single agent

• Merkel cell carcinoma if ALL of the following:

• • Individual is 2 years of age or older

  • Used as a single agent if individual has ANY ONE of the following:

  • • Recurrent regional disease and both curative surgery and curative radiation therapy are not feasible

    • Recurrent, locally advanced or metastatic disease

• Mesothelioma, Malignant Pleural, used for subsequent therapy

• Microsatellite Instability-High (MSI-H) or Mismatch Repair Deficient (dMMR) Cancer if ALL of the following:

• • Used as a single agent

  • Individual is 2 years of age or older

  • Disease must be microsatellite instability-high (MSI-H) or mismatch repair deficient (dMMR)

  • Pediatric individuals must NOT have a diagnosis of MSI-H central nervous system cancer

  • Disease is ANY ONE of the following:

  • • Bone Cancer (Ewing Sarcoma, Chondrosarcoma [excluding dedifferentiated or mesenchymal subtypes] or Osteosarcoma [excluding high-grade undifferentiated pleomorphic sarcoma]) -Used for unresectable or metastatic disease after progression following prior treatment and individual has no satisfactory alternative treatment options

    • Breast Cancer - Used for recurrent or stage IV disease that is metastatic or unresectable and has progressed following prior treatment with no satisfactory alternative treatment options

    • Cervical Cancer – For adenocarcinoma or squamous cell carcinoma and used as second-line therapy for recurrent or metastatic disease

    • Colorectal Cancer - Used in individuals with unresectable advanced or metastatic disease who are not candidates for intensive therapy as primary treatment or after primary systemic or local therapy OR Used as primary treatment for unresectable or metastatic disease after previous adjuvant treatment with FOLFOX (fluorouracil, leucovorin and oxaliplatin) or CapeOX (capecitabine-oxaliplatin) in the previous 12 months OR for unresectable advanced or metastatic disease that has progressed following treatment with a fluoropyrimidine, oxaliplatin and/or irinotecan OR Used as adjuvant treatment in patients who are not candidates for intensive therapy AND Used following resection for  synchronous liver and/or lung metastases that converted from unresectable to resectable disease after primary treatment (colon cancer only) OR Used following resection and/or local therapy for resectable metachronous metastases and has received previous chemotherapy OR Used for unresectable metachronous metastases that converted to resectable disease after primary treatment

    • Gastric adenocarcinoma OR esophageal/gastroesophageal junction adenocarcinoma or squamous cell carcinoma for subsequent therapy for unresectable (or not a candidate for surgery) locally advanced, recurrent, or metastatic disease with performance score of Karnofsky ≥60% or ECOG ≤ 2

    • Hepatobiliary Adenocarcinoma (Gall bladder cancer, intra-/extra-hepatic cholangiocarcinoma) - Used as initial therapy for unresectable or metastatic disease OR for resected gross residual disease (R2)

    • Occult Primary/Cancer of Unknown Primary (CUP) – Used for aggressive disease that is symptomatic with performance status (PS) 1-2 or asymptomatic with PS 0 AND ANY ONE of the following:

    • • Axillary involvement in men if clinically indicated

      • Lung nodules or breast marker-negative pleural effusion

      • Resectable liver disease

      • Peritoneal mass or ascites with non-ovarian histology

      • Retroperitoneal mass of non-germ cell histology in selected patients

      • Unresectable liver disease or disseminated metastases

    • Ovarian Cancer (including Epithelial Ovarian Cancer, Fallopian Tube Cancer and Primary Peritoneal Cancers) if carcinosarcoma, clear cell, endometrioid, mucinous, or serous histology for persistent or recurrent disease and individual is not experiencing an immediate biochemical relapse

    • Pancreatic Adenocarcinoma for second-line therapy for locally advanced or metastatic disease after progression OR for recurrent disease (after resection) OR as first-line therapy for metastatic disease for poor performance status

    • Penile Cancer for subsequent treatment of unresectable or metastatic disease that has progressed following prior treatment with no other satisfactory treatment options

    • Small Bowel Adenocarcinoma used as initial therapy for advanced or metastatic disease with prior oxaliplatin therapy in the adjuvant setting (or contraindication) OR as subsequent therapy for advanced or metastatic disease

    • Testicular Cancer as third-line therapy

    • Uterine Cancer (Endometrial Carcinoma) for individuals with high risk tumors, or recurrent or metastatic disease, that have progressed following prior cytotoxic chemotherapy

    • Vulvar Squamous Cell Carcinoma for advanced, recurrent or metastatic disease as second-line therapy

    • Other Solid Tumor (e.g., Adrenal Gland Tumors, poorly differentiated high-grade neuroendocrine tumors [NET], large or small cell NET, etc.) - Used for unresectable or metastatic disease progression following prior treatment and with no satisfactory alternative treatment options

• Mycosis Fungoides/Sézary Syndrome as systemic therapy for ANY ONE of the following:

• • Primary treatment for relapsed or persistent Stage III Mycosis Fungoides (MF) or Stage IV Sézary Syndrome (SS)

  • Used for stage III Mycosis Fungoides that is refractory to multiple previous therapies

• Non-Small Cell Lung Cancer (NSCLC) used for ANY ONE of the following:

• • Stage III disease if ALL of the following:

  • • First-line therapy as a single-agent

    • Individual is not a candidate for surgical resection or definitive chemoradiation

    • Tumors are expressing PD-L1 (TPS ≥1%) as determined by an FDA-approved or CLIA compliant test

    • Tumors have no EGFR or ALK genomic tumor aberrations

  • Recurrent, advanced or metastatic disease (excluding locoregional recurrence or symptomatic local disease without evidence of disseminated disease) or mediastinal lymph node recurrence with prior radiation therapy as ANY ONE of the following:

  • • First-line therapy for ANY ONE of the following:

    • • In combination with pemetrexed AND either carboplatin or cisplatin for non-squamous cell histology for tumors that are EGFR or ALK negative

      • In combination with carboplatin AND either paclitaxel or albumin-bound paclitaxel for squamous cell histology

      • Used for PD-L1 expression-positive (≥1%) tumors that are EGFR, ALK, ROS1, BRAF negative and performance status (PS) 0-2 as single agent therapy

      • Used for genomic tumor aberration (e.g., EGFR, ALK, ROS1 and BRAF) negative and PD-L1 expression <1% OR for BRAF V600Emutation positive tumors or NTRK gene fusion positive tumors in individuals with PS 0-1 for ANY ONE of the following:

      • • In combination with carboplatin AND either paclitaxel or albumin-bound paclitaxel for squamous cell histology

        • In combination with pemetrexed AND either carboplatin or cisplatin for non-squamous cell histology

    • Subsequent therapy as ANY ONE of the following:

    • • With PS ≤ 1 for genomic tumor aberration (e.g., EGFR, ALK, and ROS1) positive and prior targeted therapy OR BRAF V600E mutation positive disease OR for PD-L1 expression-positive (≥1%) tumors and EGFR, ALK negative or unknown and no prior platinum-doublet chemotherapy with ANY ONE of the following:

      • • Either carboplatin or cisplatin in combination with either paclitaxel or albumin-bound paclitaxel for squamous cell histology

        • Pemetrexed AND either carboplatin or cisplatin for non-squamous cell histology

      • Used as a single agent in individuals with a PS 0-2 and tumors expressing PD-L1 (TPS ≥1%) as determined by an FDA-approved or CLIA compliant test

    • Continuation maintenance therapy with a PS 0-2 with tumor response or stable disease following initial therapy for ANY ONE of the following:

    • • In combination with pemetrexed following a first-line pembrolizumab/pemetrexed/ carboplatin or cisplatin regimen for disease of non-squamous cell histology

      • As a single agent following a first-line pembrolizumab monotherapy regimen or pembrolizumab/carboplatin or cisplatin/paclitaxel or nab-paclitaxel regimen for disease of squamous cell histology

      • As a single agent if pembrolizumab monotherapy was given first-line for PD-L1 expression positive (TPS ≥1%) and genomic tumor aberration (e.g., EGFR, ALK, ROS1, BRAF) negative

• Primary Mediastinal Large B-Cell Lymphoma (PMBCL) if ALL of the following:

• • Individual is 2 years of age or older

  • Disease is relapsed or refractory

  • Used as a single agent

• Renal Cell Carcinoma (Kidney Cancer) if ALL of the following:

• • Diagnosed as advanced, relapsed or metastatic disease with clear cell histology

  • Used in combination with axitinib

• Small Cell Lung Cancer (SCLC) if ALL of the following

• • Used as subsequent single-agent therapy

  • Individual has ANY ONE of the following:

  • • Metastatic disease with progression on or after platinum-based treatment and at least one other line of therapy

    • PS of 0-2 with ANY ONE of the following:

    • • Relapse within 6 months following a complete or partial response or after stable disease with initial treatment

      • Primary progressive disease

• Squamous Cell Carcinoma of the Head and Neck (SCCHN) if ALL of the following:

• • Disease is unresectable, recurrent, or metastatic

  • Used as ANY ONE of the following:

  • • First-line therapy as ANY ONE of the following:

    • • Single-agent for tumors expressing PD-L1 (CPS ≥1%) as determined by an FDA-approved or CLIA-compliant test***

      • In combination with fluorouracil and a platinum chemotherapy agent

    • Subsequent therapy as ANY ONE of the following:

    • • Single-agent therapy for disease that has progressed on or after platinum-containing chemotherapy

      • In combination with fluorouracil and a platinum chemotherapy agent for non-nasopharyngeal disease

• T-Cell Lymphoma/Extranodal NK, nasal type if ALL of the following:

• • Disease is relapsed or refractory

  • Disease progressed following additional treatment with an alternative asparaginase-based chemotherapy regimen not previously used

  • Participation in a clinical trial is unavailable

• Thymic Carcinoma as second-line therapy for ANY ONE of the following:

• • Unresectable disease following first-line chemotherapy for ANY ONE of the following

  • • Potentially resectable locally advanced disease

    • Solitary metastasis

    • Ipsilateral pleural metastasis

  • Extra-thoracic metastatic disease

• Vulvar Squamous Cell Carcinoma if ALL of the following:

• • Second line therapy for advanced, recurrent or metastatic disease after progression on or after chemotherapy

  • Tumor expresses PD-L1 (CPS ≥1) as determined by an FDA-approved or CLIA-compliant test***

**If platinum treatment occurred greater than 12 months ago, the individual should be re-treated with platinum-based therapy if still eligible. (See below for cisplatin- or carboplatin-ineligible comorbidities).

1. 1. • Cisplatin-ineligible comorbidities may include the following: GFR < 60 mL/min, PS ≥ 2, hearing loss of ≥ 25 decibels (dB) at two contiguous frequencies, or grades ≥ 2 peripheral neuropathy. Carboplatin may be substituted for cisplatin particularly in those patients with a GFR <60 mL/min or a PS of 2.

      • Carboplatin-ineligible comorbidities may include the following: GFR < 30 mL/min, PS ≥ 3, grade ≥ 3 peripheral neuropathy, or NYHA class ≥ 3, etc.

***As confirmed using an immunotherapy assay @ http://www.fda.gov/companiondiagnostics

RENEWAL CRITERIA

• Pembrolizumab is considered medically appropriate for renewal if ALL of the following criteria are met:

• • Individual continues to meet initial approval criteria

  • Disease response with treatment as defined by stabilization of disease or decrease in size of

  • tumor or tumor spread

  • Absence of unacceptable toxicity from the agent, e.g., severe infusion reactions, immune-mediated adverse reactions such as pneumonitis, hepatitis, colitis, endocrinopathies, nephritis and renal dysfunction, skin reactions, etc.

  • For a diagnosis of ANY ONE of the following, the individual has not exceeded a maximum of twenty-four (24) months of therapy:

  • • Anal Cancer

    • Cervical Cancer

    • Classical Hodgkin Lymphoma (cHL)

    • Diffuse Large B-Cell Lymphoma diagnosed as Primary Mediastinal Large B-Cell Lymphoma (PMBCL)

    • Endometrial Carcinoma

    • Esophageal Cancer

    • Gastric/GEJ Adenocarcinoma

    • Hepatocellular Carcinoma (HCC)

    • Malignant Pleural Mesothelioma

    • Merkel Cell Carcinoma

    • MSI-H Cancer (including the following cancers: colorectal, pancreatic, bone,  gastric/gastroesophageal, ovarian, uterine, penile, testicular, hepatobiliary and other solid tumors)

    • Mycosis Fungoides/Sézary Syndrome

    • Non-small cell lung cancer (NSCLC)

    • Renal Cell Carcinoma (Kidney Cancer)

    • Squamous Cell Carcinoma of the Head and Neck (SCCHN)

    • Squamous Cell Lung Cancer (SCLC)

    • Thymic Carcinoma

    • Urothelial Carcinoma/Bladder Cancer

    • Vulvar Squamous Cell Carcinoma

  • Melanoma (metastatic or unresectable disease) – Refer to initial criteria

  • Non-small cell lung cancer (NSCLC) for continuation maintenance therapy must meet initial criteria

LENGTH OF AUTHORIZATION

Coverage will be provided for six months and may be renewed.

SCCHN, cHL, NSCLC, SCLC, HCC, Bladder Cancer/Urothelial Carcinoma, MPM, MSI-H/dMMR, PMBCL, Cervical, Anal, Vulvar, MCC, Mycosis Fungoides/Sézary Syndrome, RCC, Thymic, Esophageal, Gastric Cancers and Endometrial Carcinoma can be authorized up to a maximum of 24 months of therapy.

Adjuvant therapy in melanoma can be authorized up to a maximum of 12 months of therapy.

Refer to DOSAGE LIMITS below

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).

SOURCES 

Eastern Cooperative Oncology Group. (2015, May) ECOG Performance Status. Retrieved May 1, 2015 from http://ecog-acrin.org/resources/ecog-performance-status.

Lexicomp Online. (2019, December). AHFS DI. Pembrolizumab. Retrieved February 26, 2020 from Lexicomp Online with AHFS.

MICROMEDEX Healthcare Series. Drugdex Evaluations. (2020, January). Pembrolizumab. Retrieved February 26, 2020.

National Comprehensive Cancer Network. (2020). NCCN Drugs & Biologics Compendium®. Pembrolizumab. Retrieved February 26, 2020 from the National Comprehensive Cancer Network.

U. S. Food and Drug Administration. (2020, January). Center for Drug Evaluation and Research. Keytruda^® (pembrolizumab) for injection, for intravenous use. Retrieved March 3, 2020 from https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=9333c79b-d487-4538-a9f0-71b91a02b287.   

ORIGINAL EFFECTIVE DATE:  9/18/2014

MOST RECENT REVIEW DATE:   6/30/2020

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.

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