BlueCross BlueShield of Tennessee Medical Policy Manual

Verteporfin  

NDC CODE(S)

00187-5600-XX Visudyne 15 MG SOLR (VALEANT)

DESCRIPTION

Verteporfin, a synthetic benzoporphyrin derivative, is cytotoxic photosensitizing agent used in photodynamic therapy.  After intravenous infusion, treatment by nonthermal red light is required for treatment in the presence of oxygen.  Treatment with verteporfin will leave an individual temporarily photosensitive and exposure to bright light should be avoided for a minimum of five days after treatment.

POLICY

MEDICAL APPROPRIATENESS

INITIAL APPROVAL

RENEWAL CRITERIA

INDICATION(S) DOSAGE & ADMINISTRATION
All Indications

Infuse 6 mg/m2 IV over 10 minutes at a rate of 3 mL/minute per eye. One week after the first course, if no significant toxicity occurs, the second eye can be treated, if necessary. 

Approximately 3 months later, the eye(s) can be evaluated for re-treatment

LENGTH OF AUTHORIZATION

Coverage will be provided for a period of 3 months and may be renewed

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

BlueCross BlueShield Association. Medical Policy Reference Manual. (3:2018). Photodynamic therapy for choroidal neovascularization (9.03.08). Retrieved September 12, 2018 from BlueWeb.

Lexi-Comp Online. (2018). AHFS Dl. Verteporfin (EENT). Retrieved September 12, 2018 from Lexi-Comp Online with AHFS.

MICROMEDEX Healthcare Series. Drugdex Drug Evaluations. (2018, February). Verteporfin. Retrieved September 11, 2018 from MICROMEDEX Healthcare Series.

U.S. Food and Drug Administration. (2016, May). Center for Drug Evaluation and Research. Visudyne® (verteporfin for injection), for intravenous use. Retrieved September 11, 2018 from http://www.accessdata.fda.gov/drugsatfda_docs/label/2016/021119s027lbl.pdf.

ORIGINAL EFFECTIVE DATE:  12/1/2016

MOST RECENT REVIEW DATE:  10/9/2018

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

All indications

1 billable unit = 0.1 mg

150 billable units every 3 months per eye

Note: Max units are doubled to 300 billable units when the claim is submitted with bilateral ICD 10 codes